HYDROTHERAPY1 

. — • — 

FOR 

STUDENTS  AND  PRACTITIONERS 

OF 

MEDICINE 


Embodying  a  consideration  of  the 

Scientific  Basis,  Principles  and  Practice 

of  Hydrotherapy  and  some  allied  Branches  of 

Physiologic  Therapy 


BY 


GEORGE  KNAPP  ABBOTT,  M.  D. 

Dean  of  the  Faculty  and 

Professor  of  Hydrotherapy  and  Practice  of  Medicine 
in  the  College  of  Medical  Evangelists 


Loma  Linda,  Cal. 

THE    COLLEGE    PRESS 
1911 


r\  v  -     n 

HI 


Copyright,  1911,  by  The  College  Press 
Loma  Linda,  Cal. 


TO   THOSE 
WHO  ARE  SEEKING  TO   BE 

CO-WORKERS 

WITH   THE 

GREAT  PHYSICIAN 

IN  THE  HEALING  OF  DISEASE  BY  THE  USE  OF 
NATURE'S  REMEDIES 


PREFACE 


NO  APOLOGY  need  be  given  for  the  presentation  of  a  work  on  hydro- 
therapy.  In  spite  of  the  advances  made  in  modern  physiologic  therapy 
in  general,  hydrotherapy  is  still  a  branch  of  therapeutics  but  little 
used  by  the  general  practitioner.  The  reason  is  not  difficult  to  find.  As  a 
science  it  receives  but  scant  attention  from  teachers  of  therapeutics,  and  in 
the  medical  curriculum  is  usually  allotted  a  few  hours  from  the  combined 
course  on  materia  medica  and  therapeutics,  which  is  already  over  crowded 
by  the  presentation  of  a  needlessly  large  number  of  preparations  of  doubt- 
ful or  very  limited  usefulness.  As  an  art  even  less  time  is  devoted  to  it. 
It  must,  however,  be  acknowledged  that  this  brief  consideration  is  a 
distinct  advance  over  twenty  years  ago,  when  the  medical  curriculum  was 
quite  innocent  of  even  a  mention  of  physiologic  therapy. 

It  is  the  author's  firm  belief,  strengthened  by  years  of  experience  in  the 
teaching  of  both  medical  students  and  nurses,  that  the  student  or  practi- 
tioner should  first  acquire  a  knowledge  of  the  technique  of  hydrotherapy  in 
the  same  way  that  nurses  are  taught,  i.  e.,  by  actual  drill  under  an  experi- 
enced instructor.  Insistence  upon  accurate,  personal  observation  of  patients 
during  their  treatment  will  help  to  strengthen  in  the  mind  of  the  student 
the  necessity  for  close  clinical  observation.  In  the  management  of  disease, 
such  observation  can  not  be  replaced  by  instruments  of  precision.  In  this 
connection  we  can  not  refrain  from  expressing  our  opinion  that  instruction 
in  practical  therapeutics  and  the  care  of  patients  should  not  be  left  to  the 
later  years  of  the  medical  curriculum. 

With  this  practical  knowledge  of  the  visible  results  to  be  obtained,  the 
student  should  devote  careful  study  to  the  physiologic  and  therapeutic  effects 
of  each  representative  class  of  treatments.  This  study  should  include  per- 
sonal laboratory  investigation  into  the  effects  of  thermic  and  mechanical 
stimuli  upon  blood  pressure,  the  heart  rate  and  force,  general  changes  in 
blood  distribution  and  its  cellular  composition,  muscular  capacity,  and  meta- 
bolic changes  as  revealed  by  chemical  examination  of  the  the  excretions, 
particularly  the  urine. 

In  the  presentation  of  the  subject,  the  author  has  tried  to  preserve  the 
closest  connection  between  experimental  physiology  and  therapeutic  deduc- 
tions and  recommendations.  We  have  at  all  times  endeavored  to  seek 
out  a  reason  for  the  results  obtained  in  practice.  It  is  only  in  this  way  that 
varying  conditions  may  be  successfully  met. 

The  modern  search  for  "specifics"  has  greatly  aided  in  the  development 
of  scientific  medicine.  The  same  principles,  however,  must  not,  without 
modification,  be  applied  to  hydrotherapy.  Specific  results  are  to  be  sought 
by  proper  adaptation  of  the  treatment  to  the  individual  case  in  hand,  rather 
than  by  rigid  adherence  to  this  or  that  type  of  application.  For  this  reason 
physiologic  effects  have  been  dwelt  upon  quite  at  length  and  have  been  con- 
sidered apart  from  the  technique. 


vi  PREFACE 

The  subject  of  therapeutics  has  been  presented  with  a  view  to  the  eluci- 
dation of  basic  principles.  It  is  the  morbid  physiologic  or  structural  state 
present  in  a  given  disease  that  requires  treatment  rather  than  the  "disease" 
as  an  entity.  Diseases  most  amenable  to  hydrotherapy  have,  therefore,  been 
grouped  in  classes  according  to  the  general  principles  involved  in  their  treat- 
ment, after  an  explanation  of  which,  each  disease  is  given  particular  atten- 
tion. 

While  hydrotherapy  is  the  most  important  branch  of  physiologic  therapy, 
it  is  not  by  any  means  a  "cure  all."  The  border  line  between  physiologic 
and  radical  therapeutics  can  not  be  drawn  by  disease  lists  but  must  be  settled 
by  rational,  conscientious  consideration  of  the  ends  to  be  sought  and  the 
trend  of  the  morbid  condition  in  hand. 

In  the  presentation  of  this  work,  the  author  lays  no  claims  to  originality. 
In  addition  to  personal  experience,  all  available  sources  of  information  have 
been  drawn  upon.  The  text  matter  and  diagrams  are  those  used  by  the 
author  in  his  lectures  to  medical  students.  The  part  on  technique  is  an 
amplification  of  a  brief  treatise  on  the  "Technique  of  Hydrotherapy"  pub- 
lished by  the  author  in  1908. 

G.  K.  A. 

LOMA  LINDA,  CAL. 
APRIL,  1911 


CONTENTS 

PART   I 
Scientific  Basis  and  Physiologic  Effects 

CHAPTER  I 
THE  PHYSICAL  PROPERTIES  OF  WATER 

Communication  and  Absorption  of  Heat.  Physics  of  Heat.  Calories. 
Specific  Heat.  Latent  Heat.  Thermic  Stimuli.  Mechanical  Stimuli.  Sol- 
vent and  Chemical  Properties. 3—8 

CHAPTER    II 
PRINCIPLES  OF  EFFECTS  AND  THERAPY 

Therapy  from  Within.  Warm  and  Cold-blooded  Animals.  Intrinsic  Ef- 
fects. Reaction.  Types  and  Degrees  of  Reaction.  Conditions  Influencing 
Reaction.  Common  Names  of  Temperatures. 9—16 

CHAPTER    III 

ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 
Muscular  and  Elastic  Tissue.     Blood  Vessels.     Lymphatics 17—21 

CHAPTER    IV 
THE  PERIPHERAL  HEART 

Traube-Hering  Waves.  Principles  of  Vascular  Effects.  Quantity  of  Cir- 
culating Fluid 22-27 

CHAPTER    V 
ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN     (Continued) 

Sudoriparous  Glands.  Summary  of  Perspiratory  Influences.  Sebaceous 
Glands.  Absorption  by  the  Skin.  Cutaneous  Respiration.  The  Skin  a  Heat 
Regulator.  Nerves  of  the  Skin. 28—32 

CHAPTER    VI 
THE  CIRCULATION— REFLEX  EFFECTS 

Reflex  Areas.  Reflex  Arc.  Special  Reflex  Areas.  Classes  of  Reflex 
Effects.  Special  Reflex  Effects. 33—43 

CHAPTER     VII 

THE  CIRCULATION— HYDROSTATIC  EFFECTS 
Principles  of  Hydrostasis.      Law   of   Antagonism.      Areas   for   Deriva- 


viii  CONTENTS 

tion.  ..  44-49 

CHAPTER     VIII 

THE  CIRCULATION— BALANCE  BETWEEN   REFLEX 
AND  HYDROSTATIC  EFFECTS 

Laws  of  Balance.     Examples 50—51 

CHAPTER     IX 
THE  CIRCULATION-BLOOD  PRESSURE 

•  Force  of  Heart  Beat.     Amount  of  Circulating  Fluid.     Vascular  Calibre 
and  Action.     Muller's  Laws. 52—58 

CHAPTER     X 
THE  CIRCULATION— CHANGES  IN  COMPOSITION  .OF  THE  BLOOD 

Corpuscular  Elements.  Mechanism  of  Distribution.  Viscosity  and  Reac- 
tion. Practical  Application.  59—63 

CHAPTER     XI 
NITROGENOUS  METABOLISM  AND  EXCRETION 

Effects  of  Cold.  Nitrogen  Economy.  Urea  and  Ammonia.  Uric  Acid  and 
Purin  Bases.  Extractives.  Phosphoric  Acid.  .  Sulphates  and  Chlorides. 
Effects  of  Heat. - ...64— 72 

CHAPTER     XII 

RESPIRATION'— RESPIRATORY  CHANGES  AND 
CARBONACEOUS   METABOLISM 

Tidal  Air.     Gaseous  Interchange.     Carbon  Dioxide.     Oxygen 73—75 

CHAPTER     XIII 
MUSCULAR  CAPACITY 

Effects  of  Cold.  Effects  of  Heat.  Ergograph  and  Dynomometer  Experi- 
ments  76—80 

CHAPTER    XIV 
THE  HEAT  MECHANISM 

Regulation  of  Heat  Production.  Regu'ation  of  Heat  Loss.  Experiments 
in  Heat  Production  and  Elimination.  Summary 81—89 

PART     II 
THERAPEUTICS 

CHAPTER     XV 
THE  REALM  AND  LIMITATIONS  OF  PHYSIOLOGIC  THERAPY 

Functional  and  Organic  Diseases.  Natural  Means.  Radical  Means. 
Basic  Principles  of  Therapy.  93—95 


CONTENTS  ix 

CHAPTER    XVI 

FEVER   AND  ANTIPYRETIC  EFFECTS 

Causes  of  Pyrexia.  Symptoms  of  Fever.  Principles  of  Antipyresis. 
Toxic  Vasomotor  Paralysis.  Medicinal  Antipyretics.  Rationale  of  Hydria- 
tic  Antipyretics.  Pathogenesis  of  Fever.  Variations  that  Produce  Fever 
and  their  Relation  to  Treatment 96-107 

CHAPTER     XVII 
THE  TREATMENT  OF  FEVERS 
Typhoid  Fever.     Malaria.    Measels.     Scarlet  Fever.     Influenza.  ..108— 126 

CHAPTER    XVIII 
INFLAMMATIONS   AND  ANTIPHLOGISTIC  EFFECTS 

Derivation.  Fluxion.  Revulsion.  Pathogenesis  of  Inflammation.  Prin- 
ciples of  Treatment.  .1 127—134 

CHAPTER     XIX 
THE  TREATMENT  OF  INFLAMMATIONS 

Inflammations  of  the  Eye.  Erysipelas.  Otitis  Media.  Mastoiditis. 
Alveolar  Abscess.  Pharyngitis.  Tonsilitis.  Boils.  Septicemia.  Poison 
Ivy.  Pneumonia.  Bronchopneumonia.  Pleurisy.  Pericarditis.  Myocardi- 
tis. Rheumatic  Fever.  Meningitis.  Biliary  Inflammations.  Appendicitis. 
Pelvic  Inflammations.  Phlebitis.  Mucous  Colitis.  Cystitis.  Specific 
Urethritis 135-155 

CHAPTER    XX 
STIMULANTS  AND  TONICS 

Hydriatic  Tonics.  Anemia.  Neurasthenia.  Splanchnic  Neurasthenia. 
Hysteria.  Dyspepsia.  Insomnia.  Chronic  Inebriety.  Chronic  Articular 
Rheumatism.  Diabetes.  Sunstroke.  Valvular  Heart  Disease.  Obesity 
with  Fatty  Heart.  Excitant  and  Stimulating  Effects.  Uterine,  Vesical  and 
Intestinal  Stimulants 156—179 

CHAPTER    XXI 
SEDATIVE  EFFECTS 

General  Sedatives.  Pure  Sedatives.  Tonic  Sedatives.  Local  Sedatives. 
Insomnia.  Chorea.  Paralysis  Agitans.  Spastic  Spinal  Paralyses.  Loco- 
motor  Ataxia.  Parenchymatous  Goitre.  The  Relief  of  Pain.  Ulcer. 
Hemorrhoids.  Neuralgia.  Tenesmus.  Dysmenorrhoea.  Renal  and  Biliary. 
Colic.  Burns.  Sprains  and  Bruises.  Fractures 180—196 

CHAPTER     XXII 
EXPECTORANT  EFFECTS 

Colds.  Acute  Coryza.  Acute  Bronchitis.  Croup.  Asthma.  Chronic 
Bronchitis 197—200 

CHAPTER    XXIII 
DIAPHORETIC  EFFECTS 
Obesity.     Icterus.     Systemic  Poisoning.     Internal  Congestions.  __201— 204 


x  CONTENTS 

CHAPTER     XXIV 
DIURETIC  EFFECTS 

Gout  and  Chronic  Rheumatism.  Bright's  Disease.  Uremia  and  Eclamp- 
sia.   205—218 

CHAPTER    XXV 
PEPTOGENIC  EFFECTS 

Atonic    Dyspepsia.     Gastrectasia.     Hypochlorhydria.     Hyperchlorhydria. 
219-223 

CHAPTER    XXVI 
HEMOSTATIC   EFFECTS 

Epistaxis.  Pulmonary  Hemorrhage.  Gastric  Hemorrhage.  Uterine 
Hemorrhage.  Apoplexy. 224—225 

CHAPTER    XXVII 
HYDROTHERAPY  IN  SURGERY 

Preparatory  Treatment.  Immediate  Care.  Surgical  Shock.  Vasomotor 
and  Cardiac  Changes.  Hydriatic  Treatment  of  Shock.  Drug  Treatment  of 
Shock.  After-Treatment.  _  --226-238 


PART    III 
TECHNIQUE 

LOCAL  APPLICATIONS  OF  HEAT 

Fomentations.  Hot  Compress.  Stupes.  Alternate  and  Simultaneous 
Hot  and  Cold  Treatments.  Hot  Water  Bottles.  Hot  Water  Coil.  Radiant 
Heat 241-246 

LOCAL  APPLICATIONS  OF  COLD 

Cold  Compress.     Ice  Pack.      Ice  Cravat.      Ice  Bag.      Cold  Water  Coil. 
246-248 

HEATING  COMPRESSES 

Moist  Chest  Pack.  Dry  Chest  Pack.  Moist  Abdominal  Bandage.  Heat- 
ing Throat  Compress.  Heating  Joint  Compress. 248—252 

POULTICES 
White  Clay  and  Glycerine.     Charcoal 252 

TONIC  FRICTIONS 

Cold  Mitten  Friction.  Wet  Hand  Rub.  Cold  Towel  Rub.  Wet  Sheet 
Rub.  Dripping  Sheet  Rub.  Ice  Rub.  Salt  Glow 252-256 

SPONGING 

Hot,  Cold  and  Tepid  Sponge.     Saline  Sponge.     Alkaline  Sponge.     Vinegar 


CONTENTS  xi 

and   Salt  Rub.      Alcohol  Rub.      Witchhazel  Rub.      Menthol  Rub.      Soap 
Wash 256-258 

RUBS  AND  FRICTIONS 
Centripetal  Friction.     Oil  Rub.     Talcum  Rub.     Dry  Friction 258-261 

BATHS 

Partial  Immersion.  Hand  and  Arm  Bath.  Foot  Bath.  Leg  Bath.  Sitz 
Bath.  Hot  Half-Bath.  Full  Immersion  Baths.  Hot,  Cold  and  Neutral 
Tub  Baths.  Brand  Bath.  Graduated  Bath.  Cold  Shallow  Bath.  Hydro- 
electric Baths.  Medicated  Baths.  Nauheim  Bath.  Russian  Bath.  Vapor 
Bath.  Turkish  Bath.  Superheated  Air  Bath.  Electric  Light  Bath. 
261-274 

SHAMPOOS 
Swedish  Shampoo.     Tub  Shampoo.     Turkish  Shampoo 274—275 

PACKS 

Full  Hot  Blanket  Pack.  Dry  Blanket  Pack.  Trunk  Pack.  Pelvic  Pack. 
Hip  and  Leg  Pack.  Hot  Packs  with  Ice  Bags.  Electro-thermal  Pack. 
Evaporating,  Neutral,  Heating  and  Sweating  Wet  Sheet  Packs.  Heating 
Trunk  Pack.  Hot  and  Heating  Trunk  Pack.  Heating  Pelvic  Pack.  276—285 

SPRAYS  AND  DOUCHES 

Shower  Bath.  Spray  Bath.  Revulsive,  Alternate,  Percussion  and  Spray 
Douches.  Spray  and  Douche  Prescriptions.  Affusions.  Pail  Pour.  285—290 

ENEMATA 

Hot,  Cold  and  Graduated  Enemata.  Cold  and  Alternate  Rectal  Irriga- 
tion. Coloclyster.  Saline  Enema.  Proctoclysis.  Soap-suds,  Oil,  Asafoe- 
tida,  Glycerine  and  Epsom  Salts,  Starch,  Quassia,  Quinin  Enemata. 
290—297 

VAGINAL  IRRIGATION 

Hot,  and  Alternate  Hot  and  Cold  Vaginal  Irrigation.  Disinfectant  and 
and  Styptic  Vaginal  Irrigation 297—299 


ILLUSTRATIONS 

FIGURE  PAGE 

1.  Expansion  of  Water  at  Different  Temperatures 4 

2.  Comparative  Thermometer  Scales 5 

3.  Diagram  Illustrating  Time  Factor  in  Intrinsic  and   Reactionary 

Effects 12 

4.  Origin  of  Lymphatic  Vessels  in  a  Papilla  of  the  Hand  (Sappey) 19 

5.  Superficial  Lymphatics  of  the  Arm  (Sappey) 20 

6.  Valves  of  the  Mesenteric  Chyliferous  Vessels  (Delamere) 20 

7.  Blood  Pressure   Tracings  Showing  Traube-Hering  Curves  taken 

from  a  Dog  (Martin) 23 

8.  Rhythmical  Vasomotor  Waves  of  Blood  Pressure  in  a  Dog 24 

9.  Diagram  to  Show  Vasomotor  Reflex  Arc  (Howell) 35 

10.  Arterior  Reflex  Areas  (Kellogg) 39 

11.  Sphygmograph  Tracing  Showing  Effect  of  Proximal  Application 

on  Pulse  Wave  (Kellogg) 41 

12.  Plethysmographic  Tracing  Showing  Effect  of  Proximal  Applica- 

tion on  Volume  Curve  (Kellogg) 41 

13.  Volume  Curve  of  Right  Arm  During  a  Hot  Sitz  Bath  Showing 

Derivative  Effect  (Winternitz) 45 

14.  Volume  Curve  of  Right  Arm  During  a  Cold  Sitz  Bath  Showing 

Retrostatic  Effect  (Winternitz)  46 

15.  Curve  Showing  Effect  of  a  Sudden  Rise  in  the  Arterial  Resist- 

ance on  the  Output  and  Volume  of  the  Ventricles  (Starling) 53 

16.  Cardiometer  Tracing  Showing  Effect  of  Increasing  the  Volume 

of  Circulating  Fluid  on  the  Total  Output  and  Volume  of  the  Heart 
(Roy) 55 

17.  Plethysmographic  Tracing  of  Spleen,  Showing  the  Spontaneous 

Rhythmical  Contractions  of  this  Organ  (Howell) 61 

18.  Curve  Showing  the  Effect  of  Cold  Treatment  on  Fecal  and  Urin- 

ary Nitrogen  (Strasser) 65 

19.  Curve  Showing  Effect  of  Cold  Treatment  on  Urea,   Phosphates 

and  Ammonia  (Strasser) 66 

20.  Curve    Showing    Effect  of  Cjld  Treatment   on  the  Oxidation  of 

Purins  (Strasser) 68 

21.  Curve  Showing  Effects  of  Cold  Treatment  on  the  Alkaline  and 

Earthly  Phosphates  (Strasser) 70 

22.  Ergograms  Showing  Effect  of  Cold  Bath  on  Muscular  Capacity 76 

23.  Ergograms  Showing  Effect  of  Graduated  Bath  on  Muscular  Ca- 

pacity..  77 


xiv  ILLUSTRATIONS 

24.  Ergograms  Showing  Effect  of  Graduated  Bath  on  Fatigue 77 

25.  Ergograms  Showing  Effect  of  Cold  Wet  Sheet  Rub  on  Fatigue 78 

26.  Ergograms  Showing  Effect  of  Warm  Douche  on  Fatigue 78 

27.  Rubner's  Chart  Showing  Manner  of  Heat  Loss  at  Different  Tem- 

peratures   83 

28.  Diagram  Showing  Quantitative  Relation  Between  the  Tempera- 

ture-Raising and  the  Temperature-Lowering  Capacity  of  Differ- 
ent Treatments 104 

29.  Diagram  Showing  Dynamic  Conditions  in  Valvular  Heart  Disease 170 

30.  Diagram  to  Show  the  Effects  of  Heat  and  Cold  in  Lessening  the 

Pain  of  Inflammation  (Brunton) 183 

COLORED  PLATES 

I.     The  Ihnervation  of  the  Heart  (Powell) opp.    35 

II.     Reflex  Arc  from  Skin  to  Heart opp.    37 

III.     Depletion  by  Simultaneous  Heat  and  Cold opp.  127 


PART    I 


SCIENTIFIC  BASIS 


AND 


PHYSIOLOGIC  EFFECTS 


CHAPTER    I 
THE  PHYSICAL  PROPERTIES  OF  WATER 


In  the  application  of  any  therapeutic  agent,  it  is  essential  to  obtain  an 
understanding  of  those  properties  of  the  agent  itself  of  which  particular 
use  is  made  in  the  treatment  of  disease.  In  the  case  of  water,  these  essen- 
tial properties  may  be  discussed  under  the  following  heads:— 

1.  Its  ability  to  communicate  or  absorb  large  quantities  of  heat  by  contact. 

a.  Specific  Heat. 

b.  Latent  Heat. 

2.  The  intensity  of  thermic  stimuli  obtained  by  the  use  of  water. 

3.  Its  convenience  in  applying  mechanical  stimuli. 

4.  Its  solvent  properties  and  use  in  nutritive  and  metabolic'  changes. 

1.  Communication  and  Absorption  of  Heat.  Hydrotherapy  consists 
chiefly  in  the  application  of  heat  and  cold  to  the  body  by  means  of  water. 
Its  most  helpful  results  are  obtained  from  the  heat  applied.  In  its  most 
scientific  and  practical  phases  it  is  a  study  of  thermotherapy.  This  being 
true,  in  the  power  of  water  to  communicate  and  absorb  large  quantities  of 
heat,  without  itself  undergoing  a  corresponding  change  in  temperature,  lies 
its  most  useful  property.  To  rightly  apply  so  powerful  an  agent,  one  should 
understand  the  physics  of  heat  as  it  applies  to  water.  A  brief  summary 
of  this  subject  will  not  therefore  be  out  of  place. 

Physics  of  Heat 

When  heated,  the  particles  of  any  substance  separate  slightly,  thus 
moving  more  freely  upon  each  other  when  hot  than  when  cold.  Solids  are  thus 
made  softer,  more  porous  and  pliable.  With  some  solids  this  is  so  marked 
that  they  may  be  moulded  into  various  shapes  even  before  hot  enough  to 
become  liquids.  The  body  tissues  are  likewise  made  soft  and  pliable  through 
the  influence  of  heat.  The  skin  is  expanded,  the  muscles  relaxed  and  the 
blood  vessels  dilated. 

In  general,  heat  expands  all  substances,  some  however  to  a  greater 
degree  than  others.  Each  metal,  for  example,  shows  a  definite  degree  of 
increase  in  bulk  when  heated.  Water  expands,  occupying  more  space  as  its 
temperature  increases  above  4°  C.  (39.2°  F.).  Nearly  all  substances  con- 
tinue to  contract  indefinitely  under  the  influence  of  cold;  i.  e. ,  the  with- 
drawal of  heat.  But  water,  after  cooling  to  4°  C.  expands  until  frozen. 
Four  degrees  C.,  or  39.2°  F.,  is  therefore  said  to  be  the  point  of  maximum 
density  of  water.  (Fig.  1)  At  this  temperature  a  given  weight  of  water 
occupies  (is  crowded  into)  the  least  possible  space.  It  is  because  of  this 


4  PROPERTIES  OF  WATER 

change  (expansion)  in  freezing  that  ice  floats.  If  water  continued  to  con- 
tract on  freezing,  it  then  being  denser,  would  sink  to  the  bottom,  and 
BO  remain  frozen  for  a  much  longer  time,  as  solar  heat  loses  its 
effect  in  penetrating  so  far.  Did  this  occur,  only  very  shallow  bodies  of 
water  would  ever  entirely  thaw  out  at  temperatures  common  to  temperate 
and  frigid  zones. 

Degrees  or  Intensity  of  Heat.  The  intensity  or  degree  of  heat  is  measured 
by  a  thermometer,  (thermo — heat;  meter — measure).  Only  the  Fahrenheit 
and  Centigrade  scales  need  be  described.  The  Fahrenheit  thermometer, 
more  commonly  used  for  domestic  and  clinical  purposes  will  be  described 
first.  The  freezing  point  of  water  is  marked  as  32°  F.,  that  is,  32°  above 
the  zero  or  starting  point  of  this  scale.  Water  boils  at  212°  F.  above  freezing. 


«,55      853 


•».  3 


Fig.  1,     Expansion  of  water  at  temperatures  from  (f  C.  to  100°  C. 

The  Centigrade  thermometer  is  a  more  simple  instrument,  as  the  freezing 
point  of  water  is  marked  0°,  while  the  boiling  point  is  marked  100°.  From 
this  we  see  that  32°  Fahrenheit  corresponds  toO°  C.,  and  212°  F.  corresponds 
to  100 J  C.,  and  therefore  180  Fahrenheit  degrees  (212  minus  32)  are  the  equi- 
valent of  100  Centigrade  degrees  or  1.8°  F.  equal  1°  C.  (Fig.  2) 

Equivalent  Readings.  To  change  a  given  reading  on  the  Centigrade  scale 
to  Fahrenheit,  it  is  necessary  first  to  multiply  by  9-5  (180-100).  This  gives 
the  number  of  Fahrenheit  degrees  above  the  freezing  point.  Since  this 
point  on  the  Fahrenheit  scale  is  32°  above  zero,  32  should  be  added  to  the 
result  to  obtain  the  correct  Fahrenheit  reading.  For  example, — find  the 


HEAT  UNITS 


Fahrenheit  reading  which  corresponds  to  35°  C.     Multiplying  35  by  9-5  gives 
63°  above  freezing;  adding  32°  gives  95G  F. 

To  obtain  the  correct  Centigrade  reading  of  a  given  Fahrenheit  tempera- 
ture, it  is  only  necessary  to  reverse  the  process.  Take,  for  example,  98.6° 
F.,  the  normal  body  temperature  by  mouth.  This  is  66.6°  (98.6  minus  32) 
above  freezing;  66.6°  multiplied  by  579  equals  37°  C.  Since  0°  C.  is  the 
freezing  point,  this  is  the  correct  Centigrade  reading. 

Condensed  rules: — 

To  change  Centigrade  to  Fahrenheit,  multiply  by  9-5  and  add  32. 

To  change  Fahrenheit  to  Centigrade,  subtract  32  and  multiply  by  5-9. 


Heat  Units  or  Quantity  of  Heat.  a.  SPECI- 
FIC HEAT.  The  amount  of  heat  required  to 
raise  a  gram  of  water  1°  C.  is  called  a  heat 
unit,  or  calorie.  The  large  Calorie  (written 
with  an  initial  capital)  is  the  amount  of  heat 
necessary  to  raise  1000  grams  (1  liter)  of 
water  1°  C.,  and  is  therefore  equal  to  1000 
small  calories. 

The  amount  of  heat  that  would  raise  the 
temperature  of  a  given  weight  of  water  1° 
C.  would  raise  the  temperature  of  the  same 
weight  of  mercury  30°  C.  Therefore,  one 
gram  of  mercury  in  being  heated  through 
1°  C.  would  absorb  only  1-30  of  a  calorie,  i.  e., 
1-30  of  the  amount  of  heat  absorbed  by  the 
same  weight  of  water  in  being  heated  through 
1°  C.  From  this  fact  it  will  be  seen  that 
water  absorbs  a  large  amount  of  heat  without 
manifesting  a  corresponding  change  in  tem- 
perature; while  a  small  amount  of  heat  pro- 
duces a  considerable  change  in  the  tempera- 
ture of  mercury. 

The  heat  necessary  to  raise  a  given  weight 
of  water  1°  is  greater  than  that  of  any  other 
substance.  Therefore,  water  is  said  to  have 
a  high  specific  heat.  Specfic  heat  is  the  ca- 
pacity of  a  substance  for  absorbing  heat  as 
compared  with  the  capacity  of  a  standard  sub- 
stance. More  accurately,  it  is  the  amount  of 
heat  a  given  weight  of  a  substance  absorbs 
in  being  raised  in  temperature  1°  C.  as  com- 
pared with  the  amount  of  heat  necessary  to 
accomplish  the  same  rise  in  temperature  in 
the  same  weight  of  a  standard  substance. 
Since  water  absorbs  more  heat  than  any  other 
substance,  it  is  taken  as  the  standard.  A 
gram  of  mercury,  absorbing  only  1-30  the 
amount  of  heat  absorbed  by  1  gram  of  water, 
is  said  to  have  a  specific  heat  of  1-30  that  of 
water.  Copper  has  a  specific  heat  of  1-12  that  of  water. 


FAHRENHEIT  CENTIGRADE 


2IO    ' 
200 
190 
180 

iro 

160 
ISO 


no 

iOO 


90 


80 


70 


60 


50 


40 


70 
60 

SO  I 

40 

mtzM  POUT 


20 


Fig.  2.    Comparative 
thermometer  scales. 


6  PROPERTIES  OF  WATER 

It  will  be  seen  from  the  preceding  discussion,  that  a  large  amount  of  heat 
is  stored  in  hot  water.  It  is  this  high  specific  heat  of  water  that  makes  it 
especially  valuable  in  applying  heat  to  the  body.  A  pound  of  hot  water 
will  communicate  thirty  times  as  much  heat  to  the  body  as  a  pound  of  mer- 
cury. And  conversely,  a  pound  of  cold  water  will  abstract  from  the  body 
thirty  times  as  much  heat  as  a  pound  of  mercury.  In  each  case  the  temper- 
ature of  the  water  or  mercury  will  be  changed  only  1°.  The  hot  water  not 
only  stores  up  a  great  amount  of  heat,  but  it  communicates  this  very  readily 
to  things  with  which  it  comes  in  contact.  Conversely,  cold  water  very 
readily  absorbs  heat  by  contact  with  other  bodies;  hence,  if  applied  to  the 
human  body,  it  quickly  cools  the  skin,  adjacent  tissues  and  their  blood  cur- 
rent. 

• 

b.  LATENT  HEAT.  A  thermometer  placed  on  ice  as  it  is  melting  and 
another  placed  in  the  water  just  after,  register  exactly  the  same  degree  or 
intensity  of  heat,  viz.,  0°  C.  Since  it  requires  heat  to  melt  ice,  a  mere 
change  in  physical  state,  we  may  very  naturally  ask,  What  becomes  of  this 
heat  when  the  solid  changes  to  a  liquid?  It  is  not  apparent  nor  manifest 
by  a  change  in  the  thermometer.  We  may  call  it  hidden  or  latent  heat. 
By  careful  experimentation,  it  is  found  that  an  astonishingly  large  quantity 
of  heat  is  absorbed  in  this  process;  in  the  melting  of  one  gram  of  ice,  suffi- 
cient in  fact  to  raise  the  temperature  of  one  gram  of  water  79.2°  C.  This 
gram  of  ice  in  melting,  therefore,  absorbs  79.2  calories,  with  no  consequent 
rise  in  the  temperature,  as  measured  in  degrees.  This  amount  of  heat  is 
made  latent.  The  latent  heat  of  fusion,  or  melting  of  ice,  is  thus  fixed  at 
79.2  calories.  This  is  the  reason  ice  cools  the  body  so  much  more  rapidly 
than  cold  water,  every  gram  of  ice  that  melts  abstracting  nearly  eighty 
times  as  much  heat  as  the  same  weight  of  water  warmed  through  1°  C.  The 
value  of  the  ice  rub  is  thus  amply  demonstrated.  For  the  same  reason  an 
ice  bag  produces  a  greater  intensity  of  effect  than  a  cold  compress. 

The  same  principle  applies  to  the  boiling  of  water  or  the  condensing  of 
steam,  except  that  a  much  greater  number  of  heat  units  is  respectively 
made  latent  or  given  off.  Water  at  the  boiling  point  registers  the  same 
degree  of  heat  as  steam  just  after  it  is  formed;  and  yet  this  change  from 
liquid  to  gas  requires  537  calories  to  each  gram  of  water.  The  latent  heat 
of  vaporization  of  water  is  therefore  537  calories. 

When  steam  condenses,  it  gives  off  this  heat.  In  this  phenomenon  lies  the 
explanation  of  the  fact  that  a  Russian  bath  gives  a  great  intensity  of  effect, 
since  much  of  the  steam  condenses,  the  water  particles  remaining  suspended 
in  the  air  of  the  room  as  a  thick  fog.  For  every  gram  of  steam  that  thus 
condenses,  537  calories  of  heat  are  liberated.  The  intensity  of  burns  pro- 
duced by  the  condensing  of  steam  directly  on  the  skin  surface  is  readily 
understood  when  this  fact  is  kept  in  mind.  The  marked  cooling  effects  of 
the  evaporating  wet  sheet  pack,  or  hot  and  cold  sponging  are  due  to  the 
large  amounts  of  heat  abstracted  from  the  body  by  the  process  of  evapora- 
tion. The  practicability  of  employing  water  in  all  three  states  of  matter 
(solid,  liquid  and  gas)  and  its  ready  change  from  one  to  another  within  a 
comparatively  short  range  of  temperature,  greatly  enhances  its  utility  as  a 
therapeutic  agent. 


THERMIC  STIMULI  7 

With  all  these  facts  before  one,  it  is  apparent  that  the  great  value  of 
water  as  a  thermic  agent  lies  in  its  exceedingly  high  specific  and  latent 
heat  coefficients. 

Specific  heat  refers  to  the  amount  of  heat  concerned  in  the  temperature 
changes  of  matter  within  a  single  state. 

Latent  heat  refers  to  the  amount  of  heat  concerned  in  the  change  of 
matter  from  one  state  to  another  without  any  change  in  temperature. 

2.  Thermic  Stimuli.    It  might,  on  first  thought,  seem  that  a  thermic  stimu- 
lus   is    identical  with  the  communicating  of  heat.      It,  however,  does  not 
depend   upon    the  amount  of  heat  communicated  to  or  absorbed  from  the 
body,  but  rather  upon  the  impression  made  upon  the  nerves.     In  this  respect, 
the  temperature  of  the  body,  or  rather,  that  of  the  skin,  may  be  said  to  be 
the  zero  of  the  "temperature  sense."     Water  of  a  temperature  above  this, 
creates  an  impression  of  heat,  while  water  below  this  temperature  gives  a 
sensation  of  cold.     A  brief  application  of  ice  may  give  a  sensation  of  cold  as 
intense  as  one  of  longer  duration.     On  the  contrary,  to  abstract  heat  from 
the  body  to  any  appreciable  extent,  the  application  must  be  more  or  less 
prolonged. 

These  thermic  stimuli  are  of  the  greatest  value  in  hydrotherapy;  we  may 
say,  equally  so  with  the  actual  transfer  of  heat.  Here,  also,  the  thermic 
capacity  of  water  makes  it  of  inestimable  value.  "The  temperature-con- 
ducting capacity  of  water  is  twenty-seven  times  greater  than  that  of  air. 
Water  conveys  to  the  skin  much  stronger  thermic  impressions  than  does  air 
at  the  same  temperature,  a  fact  easily  discovered  in  exchanging  a  room 
temperature  at  75°  F.  for  a  tub  bath  at  the  same  temperature."  ] 

And  again,  the  accuracy  with  which  we  may  regulate  the  temperature  of 
hydriatic  applications  and  so  gauge  the  thermic  impressions  as  well  as  the 
heat  communicated  or  absorbed,  makes  it  doubly  convenient  and  valuable. 

3.  Mechanical  Stimuli.    The  convenience  with  which  water  lends  itself  to 
the    application  of  various  mechanical  stimuli  is  due  to  its  most  apparent 
physical  property — fluidity.      Because  of  this  perfect  fluidity,  its  applica- 
tion can  be  controlled  to  a  nicety  not  possible  with  other  agents.     With  the 
proper  appliances,  the  amount  and  temperature  can  be  accurately  gauged. 
The  size,  form,  character  and  pressure  of  douches,  sprays  and  pours  can  be 
varied  to  suit  the  varying  needs  of  a  great  variety  of  cases.       It  is  these 
four  factors  that  govern  the  mechanical  effect  in  the  class  of  treatments 
mentioned.     Water  may  be  applied  under  very  great  pressure,  thus  enhanc- 
ing the  ihermic  effects,  or  it  may  be  applied  with  little  or  no  pressure. 

Not  only  may  water  itself  be  used  to  apply  percussion,  but  its  application 
may  be  advantageously  combined  with  percussion  and  friction  from  other 
sources,  as  in  the  wet  hand  rub  or  cold  mitten  friction.  In  this  case,  it  is 
the  bare  hand  or  rough  mitten  that  is  the  chief  source  of  friction.  The 
Brand  or  cold  rubbing  bath  is  another  example  of  this  combination  of 
mechanical  and  thermic  stimuli,  each  enhancing  each.  It  must  not  be  sup- 
posed, however,  that  the  marked  effect  of  this  form  of  bath  is  due  merely 
to  a  combination  of  the  thermic  and  mechanical  stimuli.  It  is  necessary 

1     Baruch — Principles  and  Practice  of  Hydrotherapy,  p.  31. 


8  PROPERTIES  OF  WATER 

that  water  be  used.  Apropos  of  this  question,  we  quote  the  following  from 
Baruch:  "We  would  again  insist  upon  the  fact  that  neither  in  typhoid  nor 
in  cardiac  inadequacy,  can  these  effects,  or  anything  like  them,  be  produced 
by  cold  alone  (for  that  has  been  thoroughly  tried  in  both  cases),  by  the  tem- 
porary application  of  water  alone,  of  whatever  temperature,  or  by  either 
dry  saline  or  gaseous  or  mechanical  irritants.  It  is  absolutely  necessary 
that,  not  merely  cold,  but  cold  water  should  be  used,  that  the  surface  should 
be  literally  rubbed  with  this  for  a  considerable  length  of  time. "? 

The  same  may  be  said  of  the  cold  mitten  friction.  The  astonishing  results 
of  this  procedure  can  be  obtained,  neither  by  the  application  of  cold  alone, 
nor  by  friction  with  the  dry  mitt.  It  is  only  by  vigorous  rubbing  with  the 
mitt,  dipped  in  cold  water,  that  the  maximum  effects  are  produced. 

4.  Solvent  and  Chemical  Properties.  That  these  properties  are  of  less 
importance  than  the  preceding  will  be  granted  by  those  familiar  with 
hydriatic  measures.  The  solvent  properties  of  water  are  utilized  in  the 
shampoo,  enema,  etc.  Its  value  as  a  solvent  in  the  processes  of  osmosis  and 
dialysis  are  likewise  made  use  of  in  hypodermoclysis  and  saline  enemata. 
Many  body  wastes  are  but  sparingly  soluble  and  for  this  reason  require 
large  amounts  of  water  to  hold  them  in  solution.  The  flushing  of  the  system 
consequent  on  free  water  drinking  is  therefore  one  of  the  greatest  of  all  aids 
to  elimination. 3  As  a  means  of  combining  thermic  and  chemical  stimuli,  it 
is  used  as  a  solvent  in  the  Nauheim  or  effervescent  bath,  saline  baths,  etc. 

Going  a  little  further  from  the  physical  into  the  physiologic  activities  and 
almost  outside  of  the  range  of  hydrotherapy,  unless  it  be  in  water-drinking, 
we  may  consider  water  in  its  relation  to  the  nutritive  and  metabolic  pro- 
cesses of  the  human  body.  It  is  the  medium  of  all  commerce  and  exchange 
in  the  carrying  of  nutrition  to  the  tissues,  and  wastes  from  them  to  the 
excretory  organs.  It  constitutes  75  per  cent  of  the  body  weight.  Without 
it,  life  would  be  impossible.  Not  only  is  it  concerned  in  the  mere  physical 
interchange  of  nutrient  and  waste  substances,  but  it  is  actually  necessary 
in  by  far  the  greater  number  of  all  chemical  changes  which  these  substances 
undergo. 

The  popular  belief  that  particular  virtue  resides  in  the  mineral  constituents 
of  water  used  for  hydrotherapeutic  purposes  is  almost  wholly  erroneous. 
This  is  rarely  the  case  and  is  confined  to  a  very  few  procedures  such  as  the 
Nauheim  bath  above  mentioned.  The  treatment  of  rheumatism  and  obesity 
at  various  hot  springs  derives  but  little  advantage  from  minerals  present  in 
the  water  (unless  it  be  that  "faith"  in  these  induces  the  patient  to  drink 
more  water  than  usual).  The  results  are  due  to  the  thermic  effects  of  the 
hot  water,  combined  with  regulation  of  diet  and  copious  water-drinking. 
Balneology,  the  use  of  mineral  waters  in  the  treatment  of  disease,  therefore, 
adds  little  or  nothing  to  the  science  of  hydrotherapy. 

In  addition  to  the  above  mentioned  properties  of  water,  its  universal  dis- 
tribution and  accessibility  to  all  mankind  render  these  qualities  agents  of 
wide  applicability. 

2  Baruch— Principles  and  Practice  of  Hydrotherapy,  p.  12. 

3  See  Chapter  IX,  item  2. 


CHAPTER    II 
PRINCIPLES  OF  EFFECTS  AND  THERAPY 


The  basic  principles  of  hydrotherapy  are  found  chiefly  in  an  explanation 
of  the  effects  of  heat  and  cold.  Viewed  in  this  light,  the  science  is  that  of 
themotherapy.  Effects  similar  to  those  produced  by  thermic  impressions 
can  be  obtained  by  sunlight,  friction,  percussion,  and  in  fact,  all  physiologic 
agents.  This  is  most  notably  true  of  light,  many  of  the  physiologic  effects 
of  which  *run  parallel  with  those  of  hydrotherapy.  In  fact,  thermic  and 
actinic  energies  are  so  closely  related  that  they  overlap  each  other  in  the 
visible  spectrum.  From  the  lowest  limit  of  the  scale  of  energies,  up  through 
electric  energy,  heat,  light  and  actinic  rays  to  radium  emanations  and  the 
X-Ray,  there  is  laid  out  before  the  physician  a  greater  supply  of  efficient 
curative  means  than  can  be  found  anywhere  else  in  the  whole  science  of 
therapy. 

Therapy  From  Within 

Those  agents  which,  by  their  toxic  action,  arouse  the  body  to  resist  their 
intrusion,  can  not  be  classed  as  physiologic  means.  They  excite  abnormal 
and  unusual  activities  which  are  largely  directed  against  the  toxic  agent 
itself,  rather  than  heightening  the  normal  activities  which  keep  the  body 
in  health  and  repel  the  onset  of  morbid  processes.  Merely  to  relieve  tem- 
porarily a  distressing  condition,  without  enabling  the  body  itself  to  over- 
come that  condition,  is  doing  no  permanent  good.  The  sick  can  not  always 
be  applying  special  means.  After  discovery,  they  must  depend  upon  the 
natural  surroundings  and  ordinary  agencies  which  keep  the  body  in  health. 
For  example,  to  relive  pain  by  cocaine,  an  ice  bag,  pressure  or  a  fomenta- 
tion is  productive  of  no  lasting  good,  unless  that  cocaine,  ice  bag,  pressure 
or  fomentation  causes  the  body  to  overcome  the  condition  producing  the 
pain;  and  its  repeated  application  brings  about  such  a  change  that  the  pain 
(or  diseased  condition)  does  not  reappear  after  the  curative  agent  is  with- 
drawn. The  body  must  be  made  to  "cure"  itself.  The  restorative  power 
lies  in  nature.  The  natural  God-given  forces  must  be  rejuvinated.  The 
power  from  without  must  produce  or  "arouse  power  from  within. 

Warm  and  Cold-blooded  Animals 

The  reason  that  thermic  applications  and  impressions  are  so  powerful  in 
arousing  body  functions  lies  in  the  fact  that  life  activities  are  carried  on 
only  within  a  certain  limited  range  of  temperature.  With  regard  to  body 
temperature,  there  are  two  general  classes  of  animals,  viz.,  the  warm  and 
the  cold-blooded. 

The  temperature  of  so-called  "cold-blooded"  (poikilothermic)  animals 
rises  and  falls  with  their  surroundings.  The  organism  is  not  injured  by 


10  PRINCIPLES  OF  EFFECTS  AND  THERAPY 

comparatively  wide  variations.  The  frog,  for  example,  is  lively  in  water 
at  70°  F.,  and  sluggish  in  water  at  45°  F.,  but  it  nevertheless  lives  and 
remains  normal  in  either.  These  variations  do  not  seriously  depress  vital 
activities.  The  organism  is  able  to  withstand  such  radical  changes  in  the 
temperature  of  its  blood  and  body  generally,  without  this  change  being 
inimical  to  its  life.  The  body  temperature  of  these  animals  remains  slightly 
above  that  of  the  cold  water  they  may  be  in  and  slightly  below  that  of 
warm  water.  Cold-blooded  animals  are  principally  aquatic  and  amphibian. 

Certain  other  animals  maintain  a  constant  temperature  under  varying 
conditions.  The  surrounding  air,  whether  hot  or  cold,  does  not  materially 
alter  their  body  temperature.  The  heat  mechanism  is  so  nicely  adjusted 
that  more  heat  is  produced  when  the  surrounding  medium  is  cold,  and  less 
when  the  air  or  other  medium  is  hot.  This  class  of  animals  is  called  "warm- 
blooded" (homeothermic)  because  of  the  constant  temperature  at  which 
their  blood  is  kept.  Arterial  blood  is  slightly  warmer  than  venous.  The 
ordinary  limits  for  man  are  about  101° — 103°  F. 

Organs  of  constant  activity,  such  as  the  heart,  liver  and  brain  have  a 
temperature  2C — 4°  higher  than  the  average  of  the  blood  stream.  At  ordin- 
ary room  temperature,  the  uncovered  skin  has  a  temperature  of  from  92°— 
$y  F.  This  fact  is  of  importance  in  the  adminstration  of  neutral  baths. 
The  water  should  be  1°  or  2°  higher  than  that  of  the  general  skin  tem- 
perature. This  secures  a  full  sedation  by  adding  a  slightly  relaxing  effect. 
As  noted  above,  the  internal  temperature  of  warm-blooded  animals  is  com- 
paratively a  fixed  point,  or  varies  within  only  very  narrow  limits,  not  more 
than  one  degree  in  health.  Any  radical  or  prolonged  departure  from  this 
fixed  point  (98.6°  F.  by  mouth)  interferes  with  vital  functions. 

Intrinsic  Effects 

When  the  body  becomes  thoroughly  chilled,  as  by  a  long  ride  in  the  cold, 
the  pulse  and  respiration  are  slowed,  the  circulation  is  less  rapid,  the  nerves 
benumbed,  the  muscles  respond  sluggishly  and  clumsily,  the  finer  skilled 
movements  are  impossible,  digestion  is  retarded,  the  body  temperature  is 
lowered.  Cold  is  therefore,  in  itself,  a  vital  depressant,  i.  e.,  it  retards 
vital  processes.  This  is  its  intrinsic  effect.  Kellogg  records  an  experiment 
in  which  immersion  of  the  body  in  water  at  55°  F.  for  ten  minutes  reduced 
the  pulse  rate  from  seventy-six  to  fifty  per  minute.  Another,  in  which  twenty 
minutes  in  water  at  45°  F.,  the  patient  being  rubbed  continuously,  reduced  the 
pulse  rate  from  eighty  to  fifty-eight.  Both  experiments  were  upon  healthy 
persons.  In  another  experiment,  exposure  to  cold  showed  tactile  sensibility 
decreased.  Before  the  exposure,  the  points  of  an  esthesiometer  were 
detected  as  two  separate  points  at  a  minimum  separation  of  2  mm.  After 
five  minutes  immersion  in  water  at  40°  F.,  the  minimum  distance  was  in- 
c -reased  to  6  mm.  Another,  in  which  five  minutes  in  water  at  68.4°  F., 
reduced  the  body  temperature  0.8°  F.  These  data  serve  to  make  definite, 
facts  with  which  we  are  acquainted  in  a  general  way  only. 

It  will  be  seen  from  this  that  an  overactive  process  may  be  retarded  and 
brought  back  toward  the  normal  by  an  application  of  cold,  continued  until 
it*  intrinsic  effects  are  manifest.  The  longer  the  duration  of  the  cold 


REACTION  n 

application,  the  greater  its  effect.      The  same  is  true  of  the  degree  of  cold. 
The  lower  the  temperature,  the  more  pronounced  the  effects. 

While  cold  retards,  heat  stimulates  vital  activities.  We  know  what  it  is 
to  experience  the  vivifying  effects  of  the  warmth  from  a  fire  or  sunlight  after 
being  in  very  cold  air  for  some  time.  The  circulation  is  quickened;  the 
heart  beats  faster;  respiration  is  more  rapid;  nerve  sensibility  is  heightened; 
muscular  action  is  quicker,  more  certain  and  precise,  and  digestion  pro- 
ceeds more  rapidly.  In  watching  the  activity  of  the  white  blood  cell  under 
the  microscope,  the  stage  must  be  kept  warm  or  the  movements  will  cease. 
The  amoeba,  paramcecium  and  other  one-celled  animals  exhibit  their  peculiar 
movements  only  in  the  presence  of  a  certain  amount  of  heat.  When  cold, 
their  movements  cease  entirely.  Cold,  per  se,  decreases  oxidation  and  meta- 
bolic activities;  heat  increases  the  oxidizing  capacity  of  the  tissues  and 
metabolic  activities  are  hastened. 

When  the  body  is  overheated,  its  functions  are  abnormally  increased  and, 
if  long  continued,  permanent  injury  may  result.  When  heated  only  to  a 
slight  degree,  however,  sluggish  activities  are  whipped  up  and,  if  the  appli- 
cations of  heat  are  repeated  at  intervals,  the  retarded  functions  tend  to 
return  to  normal. 

Reaction 

The  most  interesting  and  phenomenal  results  of  hydrotherapy  are  due  to 
that  complex  process— reaction,  i.  e.,  the  part  which  the  body  itself  takes 
in  its  own  recuperation  and  healing.  This  interesting  phenomenon,  in  its 
entirety,  is  observed  only  in  homeothermic  animals.  Cold-blooded  animals 
instead  of  reacting  to  their  external  medium  are  subject  to  the  vicissitudes 
of  their  environment.  On  the  contrary,  warm-blooded  animals  maintain 
more  or  less  uniformity  of  function  because  of  the  perfect  control  exercised 
over  vital  processes  by  the  nervous  system.  This  control  is  more  highly 
developed  and  complicated  than  in  poikilothermic  animals. 

We  have  seen  that  the  influence  of  cold  is  to  depress  vital  activities;  that 
is,  if  continued  long  enough,  its  intrinsic  effect  is  manifest  in  depression. 
But  let  us  notice  the  effects  of  a  brief  application  of  cold.  A  plunge  into 
cold  water  increases  the  pulse  rate  and  force,  the  skin  becomes  reddened 
because  of  a  quickened  peripheral  circulation,  and  the  respiration  is  deeper. 
The  muscles  are  energized  so  that  their  capacity  for  work  is  increased. 
These  heightened  activities  continue  for  a  time,  gradually  returning  to  nor- 
mal. Reaction  may  be  defined  as  a  group  or  series  of  changes  inaugurated 
by  the  body  because  of  some  disturbing  external  agent.  More  briefly,  it  is 
the  response  of  the  organism  to  an  external  agent. 

Rationale  of  Reaction.  The  explanation  of  these  tonic  and  stimulating 
effects  lies  in  the  recognition  of  cold  by  the  body  as  an  agent  which  will 
depress  its  functions.  Even  though  the  contact  be  too  brief  to  actually  bring 
about  this  result,  it  immediately  increases  its  activities  in  order  to  counter- 
act the  anticipated  depression.  The  body  tends  to  resist  or  overbalance 
attempts  to  alter  its  temperature.  In  doing  so  it  is  said  to  react  against 
this  change,  or  attempted  change.  Cold,  in  and  of  itself,  causes  depression. 
But  the  attempt  on  the  part  of  the  body  to  resist  this  depression  results  in 


12 


PRINCIPLES  OF  EFFECTS  AND  THERAPY 


heightened  activity.  This  is  spoken  of  as  the  reaction  or  reactionary  effect. 
It  is  always  the  opposite  of  the  intrinsic  effect.  Some  very  common  exam- 
ples of  this  will  serve  to  illustrate  the  principle.  An  ice  bag  applied  over 
the  heart  for  five  minutes  slows  the  pulse  rate,  while  slapping  the  chest 
with  a  cold  wet  towel,  or  a  short  cold  douche  to  the  chest,  increases  both  the 
pulse  and  the  respiration  rate.  A  long  cold  application,  as  a  cold  tub  bath, 
lowers  the  body  temperature,  while  a  short  cold  application,  as  a  cold  plunge 
or  cold  douche  soon  results  in  an  increase  of  body  temperature. 

If  the  external  cause  is  long  continued,  the  reaction  may  not  be  appar- 
ent, may  be  lost  or  obscured  by  the  intrinsic  effect.  The  body  reacts  or 
attempts  to  react  to  even  prolonged  applications  of  cold,  so  that  what  is 
seen  as  a  result  of  these  long  applications  is  really  a  mixture  of  the  intrin- 
sic and  reactionary  effects. l  As  to  which  shall  predominate  depends  upon 
the  intensity  and  duration  of  the  application.  With  the  more  prolonged 
applications,  the  reaction  is  suppressed  or  obscured,  while  in  those  of  inter- 
mediate duration,  we  often  see  as  much  of  one  as  of  the  other. 


TIME   UNIT 


Fig.  3.     Diagram  illustrating  the  time  factor  in  the  obtaining 
of  intrinsic  and  reactionary  effects. 

With  heat,  as  used  in  actual  practice,  we  observe  its  intrinsic  effects 
when  the  hot  application  is  short,  i.  e.,  of  brief  duration.  The  first  effect 
of  heat  is  that  of  a  stimulant  and  tonic;  but,  if  long  continued,  depression 
results.  This  depression  is,  by  some,  termed  "a  reaction. "  Baruch  objects 
to  this  term  as  applied  to  heat.  If  we  define  reaction  as  the  vital  response 
to  an  external  force,  or  the  attempt  on  the  part  of  the  organism  to  counter- 
act an  external  agent,  we  can  see  no  great  objection  to  the  term,  or  to  say- 
ing that  the  reaction  to  heat  is  of  an  atonic  nature. 

1  In  discussing  these  two  classes  of  effects,  intrinsic  and  reactionary,  some  writers  use  the 
term  "primary''  as  synonymous  with  intrinsic  and  the  term  "secondary"  as  synonymous  with  re- 
action. Since  the  intrinsic  effect  of  cold  is  neither  primary  in  point  of  time,  nor  in  all  cases  pri- 
mary in  importance,  the  term  leads  to  confusion.  The  same  may  be  said  of  the  expression, 
"secondary."  The  reaction  often  appears  before  the  intrinsic  depressant  effect  of  the  cold  be- 
comes manifest  and  so  can  not  be  said  to  be  secondary  as  far  as  time  is  concerned.  Also,  if  from 
a  certain  application  a  reaction  is  desired,  then  the  reaction  can  not  be  said  to  be  secondary  in 
importance.  For  these  reasons  we  object  to  the  terms  as  demanding  different  definitions  under 
different  circumstances  of  use.  They  must,  therefore,  prove  confusing. 


REACTION  1S 

The  accompanying  diagram  (Fig.  3)  illustrates  the  relation  existing  be- 
tween the  duration  of  the  application  and  the  obtaining  of  intrinsic  and  re- 
actionary effects.  The  thick  ends  of  the  wedges  indicate  prolonged  appli- 
cations ;  the  thin  ends,  brief  applications.  Intrinsic  effects  are  shown  at  the 
left  and  reactions  at  the  right. 

Tonic  effects  are  obtained  from  the,  — 

Intrinsic  effects  of  heat  (short);  reaction  to  cold  (short). 

Retarding  and  depressant  effects  are  obtained  from  the,— 
Reaction  to  heat  (long) ;  intrinsic  effects  of  cold  (long) . 

Abrams2  makes  the  following  statement:  "Respecting  the  physiologic 
effects  of  heat,  it  suffices  to  say,  that  a  prolonged  application  of  a  high  tem- 
perature is  primarily  an  excitant,  and  secondarily,  a  depressant;  a  brief 
application,  however,  is  strongly  excitant  and  the  depressing  effects,  if  any, 
are  imperceptible."  In  discussing  the  effects  of  thermic  stimuli  (on  secre- 
tion) Pope3  says,  "In  general  terms  it  may  be  stated  that  brief  applica- 
tions of  thermic  stimuli,  whether  hot  or  cold,  stimulate  sepretion,  differing 
in  degree  rather  than  in  toto;  long-continued  applications  depress." 

It  must  not  be  concluded  from  the  above  grouping  that  the  depressant 
effects  of  a  long  cold  application  (intrinsic)  and  those  of  a  long  hot  applica- 
tion (reaction)  are  identical  in  nature.  The  depression  is  manifest  in  dif- 
ferent ways.  With  cold  the  depression  is  in  the  nature  of  a  simple  retarda- 
tion of  vital  functions,  whereas  with  the  heat  the  depression  is  manifest 
chiefly  in  the  nervous  and  muscular  systems, 4  and  is  perhaps  best  described 
as  atonic.  That  this  is  largely  a  nervous  phenomenon  is  apparent  from  the 
fact  that  a  vigorous  cold  treatment  following  prolonged  heat  often  quickly 
restores  the  patient  to  a  normal  condition. 

Phases  of  Reaction.  There  are  two  important  phases  of  reaction,  viz., 
the  circulatory  and  the  nervous.  The  circulatory  is  most  apparent  and  is 
that  by  which  we  judge  the  completeness  of  reaction.  The  skin  should  be- 
come ruddy  and  warm.  The  patient  feels  a  warm  glow  over  the  entire 
skin  surface.  There  should  be  nothing  of  stasis,  no  cyanosis  or  goose  flesh. 
The  skin  should  be  smooth,  soft  and  pliable.  The  nervous  reaction  is  appre- 
ciated not  only  by  the  patient  but  by  the  observer.  The  dull  listless  appear- 
ance of  the  eye  and  countenance  generally  gives  way  to  a  decided  brighten- 
ing. If  there  is  delirium  or  stupor,  as  in  typhoid,  pneumonia,  etc.,  it  may 
be  replaced  by  quiet  sleep.  In  fact,  the  salutary  effects  are  visible  in  all 
the  nervous  functions  of  the  body.  With  a  neurasthenic  patient  the  feeling 
of  langour,  restlessness  and  weight  in  the  abdomen  is  replaced  by  that  of 
vigor  and  exhilaration.  Another  phase  of  reaction  is  that  termed  thermic. 
It  is  the  response  of  the  heat  mechanism  to  stimulation.  It  is  of  less  prac- 
tical importance  since  it  can  not  be  conveniently  utilized  in  judging  of  the 
completeness  of  reaction. 

Types  and  Degrees  of  Reaction 

Suppressed  Reaction.  It  is  often  desirable  to  suppress  or  limit  the  re- 
action arising  from  some  application.  This  is  especially  true  with  long 

2  Spondylotherapy,  p.  175. 

3  Hydrotherapy,  p.  35. 

4  Metabolic  changes  are  hastened  by  prolonged  heat. 


14  PRINCIPLES  OF  EFFECTS  AND  THERAPY 

cold  applications  which  are  designed  to  delay  vital  activities  or  reduce  fever. 
Of  course  the  body  attempts  to  react  to  all  such  measures  as  have  been 
mentioned.  The  reaction  may  be  limited,  e.  g.,  by  a  cold  application  such  as 
an  ice  bag  to  a  part.  The  nervous  excitability  is  lessened  by  the  continuous 
and  severe  cold  so  that  the  phenomena  of  reaction  do  not  appear  in  their 
entirety  and  completeness.  In  the  case  of  a  Brand  bath,  the  exciting  stage 
soon  gives  way  to  a  slower  heart  beat,  slower  and  deeper  respiration,  etc., 
by  reason  of  the  continuance  of  the  cold.  In  general,  the  suppression  of 
the  reaction  depends  upon  the  intensity  of  the  cold  and  its  duration,  being 
greater  with  the  lower  temperatures  and  with  the  prolonging  of  the  appli- 
cation. 

Repeated  Reaction.  In  the  giving  of  alternate  hot  and  cold  treatments 
the  body  is  called  upon  to  react  several  times.  After  two  or  three  applica- 
tions, the  reactions  are  less  complete.  The  oscillatory  changes  occuring  in 
the  blood  vessels  become  less  and  less  in  amplitude  after  each  succeeding 
application.  In  order  to  produce  complete  reactions  where  the  applications 
are  repeated,  it  is  necessary  to  increase  the  intensity  of  the  stimulus.  This 
may  be  done  in  the  case  of  alternate  hot  and  cold  by  using  a  higher  tempera- 
ture for  the  hot  and  a  lower  temperature  for  the  cold  or  by  adding  mechan- 
cal  stimuli. 

Incomplete  Reaction.  Applications  not  properly  suited  to  the  reactive 
ability  of  a  patient  will  result  in  an  incomplete  reaction.  Should  this  occur, 
the  patient  experiences  quite  unpleasant  symptoms  such  as  chilliness,  shiv- 
ering, cold  feet,  a  feeling  of  fullness  in  the  head,  and  even  faintness  and 
nausea.  These  are  due  mostly  to  the  internal  congestion  which  has  not  been 
relieved  or  has  been  made  more  intense. 

Conditions  Influencing  Reaction 

Age  and  Vitality  of  Patient.  In  either  extreme  of  life  the  ability  to  react 
is  quite  limiied.  Neither  infants  nor  aged  persons  bear  cold  treatment  well. 
We  have  treated  persons  in  advanced  life  who  were  utterly  unable  to  react 
to  even  cool  water  as  applied  by  the  wet  hand  rub,  and  who  invariably 
chilled  after  a  cold  mitten  friction. 

In  certain  diseases  or  states,  the  vitality  is  so  reduced  as  to  render  reaction 
extremely  difficult.  This  is  true  of  nearly  all  those  diseases  which  produce  a 
profound  asthenia.  In  anemia  and  extreme  emaciation  the  same  conditions 
prevail.  In  all  such  cases  it  is  necessary  to  thoroughly  warm  the  body  pre- 
vious to  the  cold  application  and  give  vigorous  friction  during  and  following 
the  treatment.  Even  these  means  will  not  always  insure  a  reaction. 

Exercise,  sufficient  to  warm  the  body,  promotes  reaction.  This  is  true 
whether  taken  before  or  after  the  treatment.  It  quickens  the  circulation 
and  brings  the  blood  to  the  surface.  Body  heat  is  increased  so  that  the 
surface  blood  vessels  become  dilated  in  order  to  increase  heat  elimination. 
Fatigue  is  not  conducive  to  completeness  of  reaction.  In  case  it  is  neces- 
sary to  treat  persons  who  are  fatigued,  a  short  hot  application  should  be 
given  first,  quickly  followed  by  some  short  but  very  vigorous  cold  treatment, 
accompanied  by  friction  or  percussion. 


CONDITIONS  INFLUENCING  REACTION  15 

Warmth  of  the  Body.  When  the  body  is  warm,  reaction  appears  promptly 
The  internal  heat  of  the  body  may  be  ever  so  much  and  yet  reaction  be  im- 
possible if  the  skin  is  cold  and  clammy,  pale,  cyanotic  or  gooseflesh  in  ap- 
pearance. The  skin  should  be  warm  and,  if  possible,  ruddy  before  cold  appli- 
cations are  used.  In  case  it  is  not,  some  sort  of  hot  treatment  should  be 
used  first,  in  order  to  draw  the  blood  to  the  skin.  The  air  of  the  room  in 
which  the  patient  is  treated  should  be  warm  and  he  should  remain  in  a  warm 
room  after  treatment  until  reaction  is  complete.  It  may  be  necessary  to 
give  a  drink  of  hot  water  in  order  to  warm  the  body.  More  essential  than 
all  these  is  the  warmth  of  the  feet.  It  is  impossible  to  secure  full  reaction 
or  the  best  possible  results,  if  the  feet  are  cold.  It  should  therefore  be  a 
general  rule  that  the  feet  should  be  warmed  by  a  hot  foot  bath  or  alternate 
hot  and  cold  foot  bath  or  hot  foot  pack,  previous  to  any  and  all  treatment. 
In  the  giving  of  even  an  enema,  this  is  necessary.  After  treatment,  it  may 
be  necessary  to  provide  the  patient  with  additional  covering  either  in  the 
form  of  bedding  or  clothing  in  order  to  secure  full  reaction. 

Psychic  Attitude.  It  is  difficult  to  produce  complete  reaction  in  a  patient 
that  dislikes  certain  measures.  That  the  mind  does  exercise  an  inhibitory 
influence  over  body  functions  can  not  be  doubted  by  those  whose  practice 
brings  them  in  contact  with  profound  neurasthenia.  Those  under  great 
mental  strain,  worry  or  anxiety  react  poorly. 

Character  of  Treatment  and  Mode  of  Application.  In  all  cases  where  re- 
action is  likely  to  be  tardy,  the  cold  treatment  should  be  preceded  by  a  hot 
treatment.  In  ordinary  cases  the  hot  application  should  exceed  in  duration 
the  cold  application.  It  should  thoroughly  warm  the  body  and  make  the 
cold  a  welcome  change.  The  reaction  is  more  prompt  in  its  appearance  if 
extreme  cold  is  used  and  accompanied  by  friction  or  percussion.  The  colder 
the  water,  the  greater  the  reaction.  The  cold  treatment  should  be  given 
quickly.  The  treating  of  one  part  at  a  time  favors  the  quick  appearance 
of  the  reaction.  The  larger  an  application  or  the  more  general  the  surface 
treated,  the  less  promptly  will  the  reaction  appear.  Friction  with  the  dry 
hand  or  a  rough  towel  following  the  drying,  enhances  the  reaction.  Per- 
cussion has  the  same  effect.  The  drying  from  sprays  and  general  applica- 
tions of  water  should  be  done  as  quickly  and  as  thoroughly  as  possible.  If 
moisture  is  left  on  the  surface,  the  resulting  evaporation  cools  the  body  and 
reaction  is  delayed.  The  patient  should  be  dried  in  a  warm  room  near  the 
place  where  the  last  application  of  water  was  made.  To  properly  shape 
circumstances  so  as  to  favor  reaction,  requires  much  care  and  forethought 
on  the  part  of  the  attendant  nurse.  A  little  carelessness  may  undo  much  or 
all  of  the  benefit  which  should  accrue  from  a  given  treatment. 

Test  of  the  Reactive  Ability.  Tne  ability  to  react  to  cold  applications 
varies  with  the  climate  of  former  residence,  state  of  health,  occupation  and 
habits  of  the  patient.  As  to  the  reactive  capacity  little  can  be  determined 
by  questioning  the  patient.  Often  those  who  say  they  are  unable  to  take 
cold  baths  react  as  well  or  better  than  those  who  affirm  their  ability  to  re- 
act. What  one  calls  very  cold  another  regards  as  only  cool.  Some  persons 
consider  that  they  have  been  taking  cold  baths  when  bathing  in  water  at 
90°_95°  p.  The  response  of  a  patient  with  anemia  is  usually  in  direct  pro- 


16  PRINCIPLES  OF  EFFECTS  AND  THERAPY 

portion  to  the  degree  of  anemia.  The  state  of  the  vasomotors  and  the 
readiness  with  which  they  react  to  mechanical  stimuli  serves  as  a  rough 
test  of  the  ability  to  respond  to  cold  treatment.  This  test  is  mentioned  by 
nearly  all  writers  on  hydrotherapy.  Baruch5  makes  the  following  state- 
ment:— 

"I  have  found  that  the  response  of  the  cutaneous  circulation  to  mechani- 
cal excitation  furnishes  an  index  to  the  probable  reactive  capacity  of  the 
patient.  Passing  the  back  of  the  nail  of  the  index  finger  rapidly  but  gently 
across  the  abdomen,  and  increasing  the  pressure  of  the  nail  with  a  second 
stroke  parallel  to  the  first,  induces  a  more  or  less  deep  reddening  of  the  irri- 
tated skin.  The  rapidity  with  which  the  red  line  develops  after  the  nail  is 
removed  and  the  pressure  required  to  produce  it  afford  the  trained  eye  a 
crude  but  fairly  correct  test  of  the  patient's  reactive  capacity.  By  apply- 
ing this  test  frequently  before  each  procedure,  one  may  readily  train  the 
appreciation  of  this  test  and  thus  avoid  the  necessity  of  slow  development 
of  the  reaction  by  gradual  increase  of  the  intensity  of  the  treatment  which 
the  author  adopts  in  most  cases." 

Common  Names  of  Temperatures 

Heat  and  cold  are  relative,  not  absolute,  terms  and  must  needs  be  defined. 
This  can  not  be  done  with  accuracy  since  patients  differ  in  their  toleration 
of  heat  and  cold.  What  one  designates  as  very  cold  may  be  only  cool  to 
another.  The  most  satisfactory  way  is  to  define  the  limits  in  terms  of  de- 
grees. The  following  has  been  found  practical: 

Very  hot  104°  F.  and  above 

Hot  100°— 104°  F. 

Warm  (neutral  94°  —97°)  92°-100°  F. 

Tepid  80°—  92°  F. 

Cool  70°—  80°  F. 

Cold  -  55°—  70°  F. 

Very  cold  32°—  55°  F. 

5     Hydrotherapy,  p.  102. 


CHAPTER    III 
ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 


The  skin  is  the  key-board  of  hydrotherapy.  Comprising  as  it  does  such  a 
large  variety  of  tissue  elements  in  an  exceedingly  complicated  arrangement, 
every  part  of  which  is  directly  or  indirectly  connected  with  the  functions  of 
all  other  parts  of  the  body,  it  is  essential  that  its  more  important  functions 
and  their  anatomic  basis  should  be  well  understood.  This  is  especially  true 
of  the  vessels  and  nerves  of  the  skin  through  which  this  connection  with  the 
internal  organs  is  made,  for  by  these  connections,  the  physician  is  enabled 
to  influence  at  will  the  circulation,  and  to  a  large  extent,  all  the  other  func- 
tions of  these  organs.  Only  those  points  which  serve  to  explain  the  practi- 
cal applications  of  hydrotherapy  will  be  noticed  here. 

The  epidermal  layer  acts  as  a  protection  to  the  delicate  and  sensitive 
structures  underneath. 

The  dermis  contains  those  structures  with  which  we  are  most  concerned. 
It  is  made  up  of  two  fairly  distinct  layers — the  pars  papillaris,  upon  which 
the  epithelium  rests,  and  the  pars  reticularis  beneath  the  former  and  lying 
next  to  the  panniculus  adiposis.  The  knob-like  projections  of  the  papillary 
layer  are  of  two  types,  viz.,  those  containing  blood  vessels  (vascular  papil- 
lae) and  those  containing  nerve  endings  (tactile  papillae).  Both  layers  of 
the  dermis  consist  of  a  reticulum  composed  of  bundles  of  connective  tissue, 
surrounded  by  elastic  fibers.  '  For  the  most  part,  the  fibrous  bundles  lie 
parallel  to  the  skin  surface.  Those  fibers  nearer  the  surface  are  finer  and 
more  densely  packed,  producing  a  felt-like  texture,  while  those  of  the 
deeper  layers  nearer  the  subcutaneous  fat,  are  coarser  and  more  loosely 
arranged. 

Muscular  and  Elastic  Tissue 

Smooth  muscle  fibers  are  intimately  associated  with  the  elastic  fibers. 
The  two  together  constitute  one  of  the  most  important  anatomic  arrange- 
ments in  the  skin,  as  we  shall  see  presently.  In  many  parts  of  the  skin 
the  muscle  fibers  are  present  in  the  form  of  a  network,  contracting  diagon- 
ally. -  The  muscular  tissue  exists  mostly  as  the  erectores  pilorum  disposed 
in  bundles  in  connection  with  the  hair  follicles  and  lying  in  an  oblique  direc- 
tion through  the  thickness  of  the  skin.  These  muscle  bundles  are  sur- 
rounded and  traversed  by  elastic  fibers  so  that  they  are  enclosed  in  a  dense 
network  of  elastic  tissue,  threads  of  which  serve  as  tendons  to  connect  the 
ends  of  the  muscular  fasciculus  to  the  connective  tissue  bundles  of  the  cor- 

1  Bohm,  Davidoff  and  Huber— Text  Book  of  Histology,  p.  382. 

2  Baruch— Principles  and  Practice  of  Hydrotherapy,  p.  5. 


18 

ium.  3  The  varied  degrees  of  tension  of  the  skin  are  due  to  the  changes  in 
this  musculo-elastic  mechanism.  Baruch  lays  much  stress  upon  these  changes 
as  being  the  chief  cause  of  alterations  in  the  cutaneous  circulation,  which 
are  brought  about  by  thermic  impressions.  Under  medium  temperatures 
the  muscle  fasciculi  are  at  medium  tension  and  the  skin  is  ordinarily  pliable. 
Cold  causes  contraction  of  these  muscular  bundles  and  these,  embracing  in 
there  action  the  smaller  vessels  of  the  corium,  especially  the  terminal  capil- 
lary loops  (both  arterial  and  venous)  of  the  papilla,  produce  blanching  of 
the  skin.  Heat  relaxes  the  muscles;  the  tension  being  relieved,  the  elastic 
fibers  return  to  their  usual  condition  and  the  skin  is  again  soft,  loose  and 
pliable.  Higher  degrees  cause  increased  relaxation  up  to  a  certain  point, 
where  heightened  tension  is  again  manifest.  These  facts  explain  the  mech- 
anism and  the  great  importance  of  the  contractility  of  the  skin  in  the  pro- 
pulsive movement  of  both  blood  and  lymph.  This  contractility  supplies  the 
place  of  the  muscular  coat  of  the  blood  vessels  which  is  absent  in  this  situa- 
tion. The  elastic  fibers  forming  as  they  do,  a  fine  membrane  around  the 
blood  vessels  and  opposing  the  action  of  the  muscular  fibers  may  be  sup- 
posed to  support  vasodilatation. 

The  disappearance  of  elastic  fibers  from  the  skin  in  arteriosclerosis 
(Meissner)  where  rigidity  and  high  tension  are  essential  accompaniments, 
may  lend  color  to  this  view  and  possibly  reveal  something  of  the  pathogene- 
sis  of  high  tension  and  subsequent  vascular  sclerosis. 

The  Blood  Vessels 

The  blood  vascular  system  of  the  skin  on  the  arterial  side  is  arranged  in 
two  quite  distinct  horizontal  networks — an  upper  and  a  lower,  besides  being 
especially  abundant  about  the  hair  follicles  and  coil  glands.  The  latter 
structures  are  surrounded  by  a  basket-like  network  of  blood  vessels.  The 
lower  or  inferior  plexus  lies  in  the  deepest  part  of  the  derma.  It  consists  of 
comparatively  large  vessels.  From  this  plexus,  vessels  extend  more  or  less 
vertically  upward  to  form  the  upper  or  subpapillary  plexus.  From  this  plexus, 
vascular  loops  extend  directly  into  the  papillae  above.  "In  the  papillary 
vascular  system,  the  arteries  are  narrow  and  the  veins  wide."4 

Baruch  states  that  the  papillary  loop  may  be  so  filled  with  blood,  that  it 
may  double  and  fold  over  in  spiral  windings  until  it  occupies  almost  the  en- 
tire space  of  the  papilla.  This  capacity  for  increasing  or  diminishing  the 
size  of  the  capillary  loop  furnishes  an  important  agency  by  which  hydrother- 
apy  may  affect  the  circulation. 5 

Both  papillary  veins  and  arteries  consist  of  an  endothelial  tube  only.  Near 
the  middle  of  the  subcutaneous  tissue,  the  media  and  adventitia  appear.  In 
the  veins  the  muscular  coat  is  found  earlier,  i.  e.,  in  the  plexus  at  the  base  of 
the  derma,  where  they  also  seem  to  possess  valves. 6  In  the  case  of  the 
capillary  vessels,  these  coats  are  supplied  by  -the  musculo-elastic  tissues  of 
the  skin  itself,  as  mentioned  above.  Vasomotor  nerves  are  twined  around 
these  vessels  in  all  their  ramifications.  " 

3  Hyde  and  Montgomery— Diseases  of  the  Skin,  p.  35. 

4  Hyde  and  Montgomery— Ibid.,  p.  29. 

5  Baruch— Principles  and  Practice  of  Hydrotherapy,  p.  6. 

6  Bohm,  Davidoff  and  Huber-Histology,  p.  386. 

7  Hyde  and  Montgomery — Ibid.,  p.  29. 


THE  LYMPHATICS 

The  Lymphatics 


19 


"The  lymph  vessels  of  the  true  skin  are  also  distributed  in  two  layers— a 
deep  and  wide-meshed  plexus  (collecting  trunks)  in  the  subcutis  and  a  super- 
ficial narrow-meshed  plexus  (capillaries)  immediately  beneath  the  papillae. " 8 
The  latter  vessels  (Fig.  4.)  begin  in  the  papillae  as  an  exceedingly  fine  mesh- 
work  of  endothelial-lined  and  absolutely  closed  cul-de-sac  spaces  in  the  con- 
nective tissue.  These  culs-de-sac  divide  and  anastomose  in  a  very  free  man- 
ner. The  capillaries  of  the  subpapillary  plexus  also  posses  endothelial  walls 
of  their  own.  They  are  devoid  of  valves. 

While  the  lymphathic  capillaries  communicate  neither  with  the  connective 
tissue,  nor  with  the  blood  vessels,  they  are  nevertheless  in  very  intimate 
physiologic  relation  with  both  these  structures.  Cellular  migrations  and  os- 
motic exchanges  take  place  readily,  so  that  the  capillaries  fulfill  their  func- 
tions as  drains,  and  according  to  Renaut, 
selective  drains.  9  According  to  Unna, 
the  interspinal  spaces,  delicate  channel- 
ings  in  the  cement  substance  between 
the  epithelial  cells,  are  in  communica- 
tion with  the  lymphatic  spaces  of  the 
papillary  region  of  the  corium.  But,  as 
stated  above,  this  is  not  an  ana- 
tomic communication,  but  a  physiologi- 
cal relation  and  is  doubtless  the  path 
taken  by  substances  which  are  absorbed 
from  the  skin  surface.  Some  affirm 
that  absorption  occurs  partly  through 
the  coil  glands.  The  epithelium  of  ex- 
cretory glands  has,  however,  but  slight 
absorptive  powers.  At  their  commence- 
ment in  the  capillaries,  the  lymphatics 
have  a  capacity  equal  to  and  greater 
than  that  of  the  veins.  This  diminishes, 
the  nearer  we  approach  to  the  thoracic 
duct,  the  calibre  of  which  is  much 
smaller  than  that  of  the  vena  cava.  I0 


Fig.  4.     Origin  of  lymphatic 

vessels  in  a  papilla  of  the  hand. 

(Sappey) 


The  deep,  wide-meshed  plexus  located  in  the  subcutis,  forms  part  of  the 
superficial  lymphatics  (collecting  trunks)  of  gross  anatomy  (Fig.  5) 
are  larger,  though  very  irregular  and  sacciform  channels,  dividing  and  anas- 
tomosing freely.     The  wall  consists  of  endothelium,  together  with  an  elastic 
and    muscular  coat.     They  are  provided  with  valves  at  variable  distances. 
From   the    fingers  to  the  axillary  glands,  Sappey  counted  sixty  to  eighty. 
These  are  crescentic  folds  of  endothelium,  resembling  the  aortic  semilunar 
valves    and    arranged  in  pairs  (Fig.  6).     The    alternate    constrictions 
swellings  which  give  the  lymphatic  vessels  their  beaded  appearance  a 
to  these  valves.     According  to  Delamere,  the  supravalvular  enlarger 

8  Bohm,  Davidoff  and  Huber— Histology,  p.  387. 

9  Fourier,  Cuneo  and  Delamere-The  Lymphatics,  pp.  74,  75. 
10    Fourier,  Cuneo  and  Delamere— Ibid.,  p,  62. 


20 


ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 


are  true  contractile  sacs,  similar  to  the  lymphatic  hearts  of  batrachians. 
From  the  standpoint  of  hydrotherapy,  the  fol- 
lowing statement  by  the  same  writer  is  signifi- 
cant. He  says  that  because  of  the  elastic  fibers, 
connective  tissue  and  muscle,  the  lymphatic  walls 
are,  in  spite  of  their  fineness,  resistant,  extens- 
ible and  retractile.  They  withstand,  without 
rupture,  the  pressure  of  a  column  of  mercury  of 
from  thirty  to  forty  centimeters.  n 


10. 


12. 


We  have  noted    above   the  various  structures 
by  which  the  blood  and  the   lymph   vessels  are 


Fig.  5.  Superficial  lym- 
phatics of  the  arm,  anter- 
ior surface.  Lymphat- 
ic network  of  fingers  and 
palm.  Collecting  trunks 
nf  arm  and  forearm. 
(Sappy) 

1 1  Fourier,  Cuneo  and  Delamere — The  Lymphatics,  p.  70. 

12  Physiology  1898,  p.  289. 

l:i     Human  Physiology  1905,  p.  132. 

14     Bohm,  Davidoff  and  Huber — Histology,  p.  223. 


Fig.  6.     Valves  of  the  merenteric  chylifer- 
ous  vessels  of  the  new  born  cat.       (Delamere) 

rendered  contractile.  We  ought  now  to  consider 
briefly  the  contractility  of  the  endothelium.  This 
is  of  no  little  importance  in  those  vessels,  the 
blood  and  lymph  capillaries,  which  possess  no 
other  coats.  These  endothelial  cells  contract  and 
expand,  causing  changes  in  the  calibre  of  the 
capillary  channel.  According  to  Foster  12  these 
contractions  are  allied  to  the  changes  in  muscle 
fibers  which  constitute  contraction.  Landois  '•"• 
states  that  these  motor  phenomena  are  to  be 
observed  especially  after  irritation  in  the  living 
animal.  Schmetkin  found  nerve  fibers  distrib- 
uted in  the  large  blood  vessels,  not  only  in  the 
adventitia  and  media,  but  also  in  the  intima.  14 
It  seems,  then,  a  well  established  fact  that  all 


THE  LYMPHATICS  21 

the  parts  of  the  vascular  system,  whether  large  or  small,  arterioles,  capil- 
laries or  venules,  whether  blood  or  lymph  vessels,  of  whatever  size,  all  pos- 
sess the  power  of  contractility.  We  may  next  consider  the  behavior  of 
these  vessels  in  health,  the  extent,  frequency  and  causes  of  contraction; 
also  the  influence  of  physiologic  agents  upon  the  extent  and  frequency  of 
these  changes.  Practically  all  the  vessels  of  the  body  are  under  the  control 
of  the  nervous  system,  through  those  filaments  known  as  vasomotor  nerves, 
or  are  played  upon  by  such  contractile  mechanisms  as  the  skin,  which  is  it- 
self influenced  by  stimuli  similar  to  those  of  a  vasomotor  nature.  These 
vasomotor  fibers  are  said  to  be  of  two  classes, — first,  those  which  when 
stimulated  produce  vasoconstriction;  second,  those  that  produce  vasodilatation. 
The  controversy  as  to  the  existence  of  the  latter,  or  whether  vasodilatation 
is  produced  by  a  cessation  of  vasoconstrictor  influences,  does  not  concern  us 
in  the  practical  application  of  physiologic  measures.  While  the  vasomotors 
originate  in  more  or  less  definite  centers,  and  seem  to  be  more  abundant  in 
certain  localities  and  in  certain  nerve  trunks,  they  are  nevertheless  distrib- 
uted with  other  nerve  fibers  and  are  found  in  all  parts  of  the  body. 


CHAPTER    IV 


That  the  heart  beat  and  mere  mechanical  elasticity  of  the  blood  vessels 
(like  the  elasticity  of  rubber  tubing)  are  not  the  only  forces  concerned  in 
the  propulsion  of  the  blood  has  long  been  recognized.  In  a  case  of  hemi- 
plegia,  following  an  apoplexy,  there  is  a  decided  lowering  of  blood 
pressure  on  the  affected  side  and  a  consequent  stasis,  as  evidenced  by  the 
cyanosis  and  lowered  temperature  on  this  side.  This  can  not,  of  course,  be 
due  to  any  difference  in  the  propulsive  power  of  the  heart,  since  the  oppo- 
site side  reveals  no  such  marked  changes  in  its  circulation.  It  can  only  be 
due  to  some  disturbance  of  the  vasomotor  mechanism,  resulting  in  changes 
in  the  blood  vessels  themselves,  since  the  causative  lesion  is  confined  to  the 
nervous  system.  The  writer  was  very  forcibly  reminded  of  this  influence 
of  the  blood  vessels  on  blood  pressure  in  a  case  of  depressed  fracture  of  the 
left  cranial  vault,  the  pressure  from  which  involved  nearly  the  whole  of  the 
Rolandic  area  on  this  side,  including  the  speech  center.  The  radial  pulse  on 
the  right  side  (opposite  the  lesion)  was  scarcely  perceptible,  while  that  on 
the  left  side  was  strong  and  apparently  about  normal.  Numerous  other  ob- 
servations might  be  cited,  showing  the  effects  of  vasomotor  influences  on 
blood  pressure  and  the  circulation. 

We  may  well  ask,  what  is  the  normal  action  of  the  blood  vessels  which 
plays  such  an  important  part  in  the  propulsion  of  the  blood  and  the  main- 
taining of  blood  pressure  and  which,  when  interfered  with,  results  in  such 
marked  changes.  These  changes  are,  a  priori,  associated  with  and  dependent 
upon  alterations  in  the  calibre  of  the  vessels  themselves.  A  lowering  of 
pressure  being  due  to  a  widening  or  dilatation  of  the  vessels  and  an  increase 
of  pressure  to  the  opposite  condition,  a  narrowing  or  contraction  of  the  ves- 
sels. The  vascular  condition  entering  into  the  normal  rapidity  of  the  circu- 
lation is  neither  the  one  nor  the  other  extreme.  A  permanent  widening  of 
the  vessels  leads  to  stasis  of  blood,  while  a  permanent  narrowing  results  in 
heightened  blood  pressure,  arteriosclerosis  and  its  resultant  chain  of  dis- 
asters. 

Traube-Hering  Waves.  In  health,  there  are  continuous  and  more  or  less 
rhythmic  alterations  in  the  calibre  of  the  blood  vessels.  Speaking  along  this 
line,  Landois '  says  the  diameter  of  the  vessels  "is  subject  to  periodic  varia- 
tions, not  only  in  the  vessels  provided  with  muscular  tissue,  but  also  in  the 
capillaries — in  the  latter,  in  consequence  of  the  spontaneous  contraction  of 
the  protoplasmic  cells  that  form  their  walls."  Moreover,  Sir  Michael  Fos- 
ter states  that  these  changes  which  vary  considerably,  both  in  their  rhythm 

1     Human  Physiology  1905,  p.  180. 


TRAUBE-HERING  WAVES 


and  extent,  occur  without  any  obvious  changes  in  either  the  heart  beat  or 
the  general  circulation  and  when  the  animal  (under  observation)  is  appar- 
ently subjected  to  no  disturbing  causes.  He  regards  them  as  spontaneous, 
although  subject  to  vasomotor  control. 

In  determining  changes  in  the  amount  of  blood  in  the  arm  by  the  plethys- 
mograph,  the  fluctuations  in  volume,  as  registered  by  the  kymograph,  per- 
mit recognition  of  the  following  phenomena.  2  (Fig.  7)  1.  Pulsatory  fluc- 
tuations due  to  each  individual  heart  beat.  2.  Respiratory  fluctuations. 
3.  Certain  peri- 
o  d  i  c  fluctua- 
tions dependent 
upon  periodic- 
regulatory 
movements  of 
the  blood  ves- 
sels, particu- 
larly the  smal- 
ler vessels. 

"Waves  are 
often  observed 
on  the  blood 
pressure  curve, 
which  must 
arise  in  a  slow 
rhythmic  varia- 
tion of  the  con- 
strictor impul- 
ses sent  out 
from  the  vaso- 
motor center. 
These  waves 
are  known  as 
the  T  r  a  u  b  e- 
Bering  cur- 
ves. "3  Rela- 
tive to  the 
blood  pressure 
tracing  as  tak- 


Fig.  7.  Blood  pressure  tracings  showing  Traube-Her- 
ing  curves  taken  from  a  dog.  (Martin)  The  upper  trac- 
ing, taken  while  artificial  respiration  was  being  carried 
on,  shows  the  three  curves — the  pulse  wave,  represented 
by  each  double  stroke;  the  respiratory  wave,  covering 
about  five  pulse  waves;  and  the  vasomotor  or  Traube-Her- 
ing  wave,  the  slower  undulations  covering  five  respiratory 
waves.  The  lower  tracing,  taken  just  after  the  cessation 
of  artificial  respiration,  shows  only  the  pulse  waves  and 
the  Traube-Hering  waves. 


en  with  a  mer- 
cury manometer  (Fig.  8),  Howell4  says,  "  The  latter  waves  (Traube-Hering) 
are  .  .  .  due  to  a  rhythmic  action  of  the  vasomotor  center.  During  sleep, 
certain  much  longer,  wave-like  variations  in  the  blood  pressure  also  occur 
that  are  again  due,  doubtless,  to  a  rhythmic  change  of  tone  in  the  vasocon- 
strictor center."  Changes  similar  to  those  producing  the  Traube-Hering 
wave  may  also  be  observed  in  the  spleen  (Fig.  17). 

2  Landois — Human  Physiology,  p.  190. 

3  Starling— Elements  of  Human  Physiology,  p.  276. 

4  Physiology  1908,  pp.  564,  565. 


24  THE  PERIPHERAL  HEART 

In  discussing  periodic  variations  in  blood  pressure  Janeway 5  gives  the  fol- 
lowing: "These  are  evident  in  the  human  being  as  in  the  animal.  The  res- 
piratory and  the  Traube-Hering  waves,  and  the  other  less  rhythmical  but 
apparently  spontaneous  fluctuations  in  mean  blood  pressure,  must  be  in  mind 
during  every  clinical  experiment.  .  .  .  Exact  figures  for  the  possible 
pressure  variations  due  to  these  causes  are  hard  to  give,  but  their  extent  in 
animals,  combined  with  my  observations  on  the  changes  noted  in  patients 
from  moment  to  moment,  lead  me  to  place  30  mm.  Hg.  as  the  probable 
maximum  rise  which  may  be  attributed  to  them.  One  sees  these  larger 
fluctuations  mainly  in  patients  with  hypertension.  Ordinarily,  5 — 10  mm. 
would  be  a  liberal  estimate."  In  this  connection  Janeway  gives  a  tracing 
by  Mosso  taken  from  a  man  at  rest  in  which  the  Traube-Hering  wave  covers 
on  an  average  of  fifteen  pulse  waves,  thus  showing  a  fluctuation  recurring 
about  four  or  five  times  a  minute. 


*(i«^^ 


Fig.  8.  Rhythmical  vasomotor  waves  of  blood  pressure  in 
a  dog  (Traube-Hering  waves) .  The  upper  tracing  (1)  is  the 
blood  pressure  record  as  taken  with  the  mercury  manometer; 
the  lower  tracing  (2)  is  taken  with  a  Hurthle  manometer. 

Events  occuring  in  other  parts  of  the  body  may  give  rise  to  large  changes, 
so  that  the  arterioles  may  become  constricted  almost  to  obliteration,  or  di- 
lated to  more  than  double  their  usual  diameter.  These  observations  apply 
to  arteries,  capillaries  and  veins.  In  the  vessels  of  the  web  of  a  frog's 
foot,  direct  treatment  of  the  web  may  bring  about  the  same  changes. 

Since  these  rhythmic  vascular  changes  normally  occur  quite  independently 
of  the  heart  beat,  we  have  here  a  factor  in  the  circulation  which,  under 
proper  physiologic  stimulation,  may  be  utilized  to  relieve  that  organ  of  much 
of  its  work,  so  that  when  overburdened,  it  may  obtain  needed  rest  through 
the  slowing  of  the  rate  and  the  increasing  of  the  force  consequent  upon  this 
help.  Landois,  6  in  discussing  blood  pressure  as  altered  by  changes  in  the 
size  of  the  vessels,  mentions  the  application  of  heat  and  cold  to  circum- 
scribed areas  as  influencing  blood  pressure  through  the  vasomotor  nerves. 
It  is  to  the  applications  which  bring  about  such  changes  as  these  that  we 
MOW  turn  our  attention. 

5  Clinical  Study  of  Blood  Pressure,  pp.  112,  113;  see  also  pp.  16—21. 

6  Human  Physiology,  p.  166 


THE  PRINCIPLES  OF  VASCULAR  EFFECTS  25 

The  Principles  of  Vascular  Effects 

The  underlying  principle  of  applications  calculated  to  awaken  an  activity 
of  the  circulation  is  found  in  the  old  dictum,  ubi  irritatio,  ibi  affluxus. 
Where  there  is  an  irritation,  there  is  an  afflux  of  blood.  Rub  vigorously  the 
back  of  the  hand  and  the  skin  becomes  reddened  with  an  increase  of  blood. 
Percussion  or  a  dash  of  cold  water  produces  the  same  results.  These  are 
examples  of  what  we  may  term  physiologic  irritation.  All  forms  of  irrita- 
tion produce  an  initial  contraction  of  the  blood  vessels,  i.  e.,  the  primary 
effect  of  an  irritation  from  any  source  is  contraction.  The  oscillatory  changes 
which  soon  result  (reaction)  are  different  with  the  different  kinds  of  irrita- 
tion. In  fact,  it  is  this  reaction  with  which  we  are  principally  concerned. 
In  some  cases,  the  first  effect  is  of  no  practical  importance,  while  in  others, 
it  is  utilized.  Heat,  for  example,  causes  an  initial  vasoconstriction.  The 
secondary  vascular  contractions  are  slight  and  become  less  and  less  the 
greater  the  duration  of  the  application,  so  that  a  prolonged  application  of 
heat  results  in  a  maximum  dilatation.  The  remote  effect  is  not  a  reddening 
of  the  skin  from  quickened  circulation,  but  a  slight  duskiness  from  stasis  of 
blood  (passive  hyperemia) .  These  are  the  effects  of  a  fomentation,  heating 
compress,  radiant  heat,  etc.  The  reaction  to  heat  is  therefore  of  an  atonic 
and  depressing  nature. 

With  a  cold  application  to  the  skin,  the  first  effect  is  a  blanching  (vaso- 
constriction), but  this  is  soon  followed  by  a  reddening  (active  hyperemia) 
which,  as  we  know,  is  maintained  for  a  considerable  length  of  time  and  does 
not  result  in  a  dusky  color.  Here,  the  oscillations  in  vascular  calibre  are 
stimulated  in  such  a  way  that  they  are  greater,  more  forcible  and  do  not 
tend  to  passive  dilatation.  This  is  the  reactionary  effect  of  cold.  Mechani- 
cal irritation,  such  as  friction  and  percussion,  give  similar  results.  How- 
ever, the  two  combined  as  in  the  cold  mitten  friction,  cold  percussion  douche, 
etc.,  give  quicker,  better  and  more  lasting  effects. 

Kellogg7  records  the  following  experiment  as  showing  the  advantage  of 
mechanical  irritation,  combined  with  cold.  A  cold  compress  and  a  percus- 
sion douche,  both  at  65°  F.  were  simultaneously  administered  to  opposite 
and  corresponding  parts  for  five  seconds.  After  the  cold  compress,  the  re- 
action appeared  in  forty  seconds,  whereas,  after  the  cold  percussion  douche, 
the  circulatory  reaction  appears  in  five  seconds. 

As  the  cold  application  is  prolonged,  the  amplitude  of  the  vascular  oscilla- 
tions becomes  less  and  less  until  the  condition  is  more  nearly  that  of  a  con- 
stant vasoconstriction.  '  'Following  the  process  to  an  extreme  point,  we  find 
that,  by  intensely  low  temperatures,  the  circulation  in  the  capillaries  is  at 
first  accelerated  and  the  number  of  blood  corpuscles  diminished,  when  the 
part  becomes  pale.  Quickly  following  this  acceleration,  there  is  a  stasis  in 
the  capillaries,  while  in  the  smaller  veins  and  arteries,  the  slowing  of  the 
circulation  is  followed  by  brief  and  rapid  oscillations,  which  become  slower 
and  more  infrequent.  Slowly  the  vessels  become  more  pale,  less  transparent, 
and  finally,  the  movements  cease."  *  This  is,  of  course,  providing  reaction 
occurs  at  all,  as  it  usually  does  if  the  cold  is  applied  to  a  limited  area.  If 

7  Rational  Hydrotherapy  1901,  p.  1126. 

8  Baruch— Principles  and  Practice  of  Hydrotherapy,  p.  39. 


26  THE  PERIPHERAL  HEART 

the  reaction  does  not  occur,  as  where  there  is  a  general  application  of  cold 
without  friction,  the  skin  becomes  blanched  and  goose  flesh  appears,  due  to 
the  contraction  of  the  erectores  pilorum.  In  case  an  ice-cold  application 
remains  long  enough  on  one  part,  paralysis  of  the  vessels  results  and  a  con- 
sequent dilatation. 

Saline  substances  and  certain  gaseous  irritants,  chief  among  which  is 
COs,  when  applied  to  the  skin  also  produce  an  active  dilatation  and  contract-" 
ion  of  the  blood  vessels  which  results  in  quickened  circulation  and  increase 
of  blood  in  the  skin.  Saline  baths  are  of  ten  more  effective  than  plain  water. 
Carbon  dioxide  and  salines  are  most  effectually  used  in  the  combination  con- 
stituting the  Nauheim  or  effervescent  bath.  Here  the  cool  water  itself 
plays  some  part,  since  temperatures  somewhat  below  neutral  are  used. 
"So  marked  is  the  effect  of  this  skin  tonic  that  in  severe  cases  of  dilatation 
(of  the  heart)  the  almost  incredible  result  is  attained,  of  causing  the  apex 
actually  to  retract  three  quarters  of  an  inch  toward  its  normal  position  in  a 
single  treatment. " 9  The  heart  beat  is  decreased  in  frequency  and  increased 
in  force;  its  previously  labored  beat  gives  way  to  a  steady,  easy  movement 
and,  in  some  cases,  we  have  actually  been  unable  to  detect  murmurs  which 
were  previously  distinctly  heard.  These  results  are  by  all,  conceded  to  be 
due  chiefly,  if  not  almost  wholly,  to  the  stimulation  of  the  great  vascular 
area  of  the  skin,  the  so  called  "peripheral  heart"  or  "skin  heart."  When 
we  consider  the  magnitude  of  this  peripheral  heart,  it  no  longer  becomes  a 
wonder  that  its  influence  is  so  powerful.  Vierordt  estimates  the  combined 
calibres  of  the  capillaries  of  the  systemic  circulation  as  800  times  that  of 
the  aorta  in  cross  section.  With  this  fact  in  mind,  we  may  gather  some 
idea  of  the  magnitude  of  the  effect  produced  by  saline  and  gaseous  irri- 
tants acting  simultaneously  upon  such  a  great  system  of  contractile  tubes. 
Such  results  can  not  be  obtained  by  digitalis  or  strychnine.  That  these  results 
are  not  due  to  simple  atonic  vasodilatation  is  shown  by  the  fact  that  these 
patients  are  frequently  cyanotic,  an  evidence  of  already  existing  venous 
stasis  and  vasodilatation,  while  on  emerging  from  the  bath,  the  skin  is  of  a 
brighter  and  more  normal  color.  Neither  vasodilatation  nor  vasoconsti  iction 
are  conducive  to  a  slower,  easier  heart  beat.  The  result  is  therefore  not  a 
passive  change,  but  an  active  one. 

Electric  currents  applied  to  the  skin  also  stimulate  the  vasomotors.  Near 
the  positive  pole  vasoconstriction  is  manifest,  while  in  the  region  of  the  cath- 
ode vasodilatation  occurs.  With  alternating  or  interrupted  currents  the 
vasomotors  are  much  more  powerfully  stimulated.  This  "stimulation  is  great- 
est with  the  sinusoidal  current,  the  use  of  which  in  the  obtaining  of  vascular 
effects  will  be  mentioned  more  in  detail  in  the  part  on  therapeutics. 

The  Quantity  of  Circulating  Fluids 

When  we  consider  the  total  quantity  of  blood  and  lymph  in  the  body,  and 
the  fact  that  the  skin  and  adjacent  tissues  may  contain  a  large  share  of  this,  or 
influence  its  distribution  elsewhere,  we  see  how  powerful  an  agent  the  skin 
is  in  controlling  the  circulation  of  these  fluids  in  the  various  organs. 

About  1-13  of  the  body  weight  is  blood.     Of  this,  nearly  thirty  per  cent 

9    Baruch — Principles  and  Practice  of  Hydrotherapy,  p.  10. 


THE  QUANTITY  OF  CIRCULATING  FLUIDS  27 

may  be  contained  in  the  skin  under  the  influence  of  certain  conditions  and 
applications.  Ordinarily,  there  is  J  of  the  blood  in  the  heart,  lungs 
and  great  blood  vessels;  J  in  the  liver;  J  in  the  skeletal  muscles;  and  J  in 
other  organs.  The  circulation  of  the  skeletal  muscles  is  influenced  with 
that  of  the  skin,  and  usually  the  same  changes  occur  simultaneously  in  both. 

The  amount  of  lymph  in  the  body  is  variously  estimated  from  J  or  1-5  to 
J  of  the  entire  body  weight.  10  This  enormous  quantity  of  fluid  is  affected 
in  the  same  way  by  physiologic  applications  as  the  blood. 

Kowalski, ll  in  1901,  reported  a  series  of  experiments  undertaken  to  deter- 
mine the  effects  of  thermic  irritants  upon  the  movement  of  lymph  and  upon 
the  vasomotor  nerves  of  the  lymph  vessels.  Briefly  stated,  his  conclusions 
are  as  follows: — 

Thermic  irritants  control  the  flow  of  lymph,  not  only  indirectly,  but  also 
by  altering  the  calibre  of  the  lymph  vessels.  These  changes  are  the 
same  as  those  in  the  blood  vessels,  i.  e.,  low  temperatures  contract  them, 
while  higher  temperatures  dilate  them.  These  effects  are  produced  through 
the  nervous  system,  by  way  of  the  vasomotor  nerves.  The  vasomotor  nerves 
of  the  lymphatic  vessels  act  independently  of  those  controlling  the  blood 
vessels  and  general  circulation.  It  will  be  seen  from  this  that  the  use  of 
the  alternate  hot  and  cold  leg  bath  for  oedema  is  based  upon  demonstrated 
physiologic  facts,  the  lymphatics  as  well  as  the  blood  vessels  taking  part  in 
the  absorption  of  tissue  fluids. 

Experiments  on  the  production  of  lymph  in  the  limbs  have  also  brought 
out  in  a  very  striking  manner  the  rationale  of  massage  in  dropsy.  In  the 
resting  limb  there  is  no  flow  at  all  from  the  tissue  spaces.  Berlin  blue  in- 
jected under  the  skin  finds  its  way  into  the  lymphatics  with  extreme  slow- 
ness, unless  absorption  is  facilitated  by  kneading  the  limb  or  by  carrying 
out  passive  movements.  "Ludwig  has  shown  that  the  lymphatics  of  the 
aponeuroses  are  so  arranged  that  every  movement,  active  or  passive,  tends 
to  pump  fluid  from  the  tissue  spaces  into  the  lymphatics  and  from  the 
smaller  into  the  larger  lymph  trunks.  Experiments  on  the  production  of 
lymph  in  the  limbs  have  therefore  always  to  be  associated  with  kneading 
or  passive  movements  in  order  to  get  any  lymph  flow  at  all." 

Alternate  hot  and  cold  applications  together  with  massage  are  more 
effectual  in  oedema  than  the  combined  effects  of  all  other  known  agents. 

10  Fourier,  Cuneo  and  Delamere — The  Lymphatics,  p.  7. 

11  Blatter  fur  klinische  Hydrotherapie,  January  and  February,  1901. 

12  Starling— Fluids  of  the  Body,  p.  "2. 


CHAPTER    V 
ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

(Continued) 

The  Sudoriparous  or  Coil  Glands 

The  sweat  glands  are  distributed  throughout  the  entire  skin.  They  are 
most  numerous  in  the  axilla,  palms  and  soles,  where  they  are  also  of  unusual 
size.  And,  according  to  Krause,  there  are  between  2000  and  3000  per 
square  inch.  The  total  number  in  the  body  is  estimated  at  from  2,000,000  to 
3,000,000  and  their  aggregate  length  uncoiled  and  placed  end  to  end,  as  about 
eight  miles;  while  the  total  surface  of  the  ducts  is  estimated  at  11,000 
square  feet.  These  figures  serve  to  show  the  great  importance  of  hygiene, 
directed  toward  the  maintaining  of  their  normal  functions  and  the  tremen- 
dous effect  of  bad  hygiene  in  causing  disease. 

The  sweat  gland  consists  of  a  long  tubule,  coiled  at  the  deeper  end.  The 
globular  coil  (glomerulus)  lies  in  the  subcutaneous  fat,  or  in  the  fat  columns 
of  the  deeper  part  of  the  corium.  Next  to  the  epithelium  in  the  coiled 
part  of  the  tubule,  are  found  smooth  muscle  fibers,  disposed  longitudinally, 
or  spirally.  The  muscle  fibers  are  doubtless  concerned,  along  with  the 
erectores  pilorum,  in  the  checking  of  perspiration  which  results  from  cold 
applications.  Each  tube  is  about  four  or  five  millimeters  long.  Three- 
fourths  of  this  makes  up  the  coil. J  The  sweat  pore — that  part  of  the  duct 
lying  in  the  epidermis — is  a  wall-less  channel,  spiral  or  straight  in  course.  The 
outer  end  is  funnel-shaped.  The  pore  is  in  free  communication  with  the 
juice  spaces  of  the  epithelium,  as  was  mentioned  in  considering  the  lym- 
phatics of  the  skin.  It  will  be  seen  from  this  fact  that  the  drying  of  the 
skin  is  not  alone  a  drying  of  the  surface,  but  also  a  drying  of  the  fluid 
found  between  the  deeper  cells  of  the  epidermis.  A  capillary  network  of 
blood  vessels  surrounds  the  coiled  part  of  the  gland.  Nerves  from  the  sym- 
pathetic neurons  end  in  the  secreting  cells. 

The  secretion  of  the  sweat  glands  varies  with  the  character  and  amount  of 
food  and  drink,  the  state  of  health,  temperature  and  humidity  of  the  air, 
etc.  About  98  per  cent  is  water, 2  the  remainder  being  chiefly  salines,  pig- 
ment and  a  small  amount  of  fat.  In  twenty-four  hours,  one  and  one-half 
or  two  pints  of  water  are  excreted.  This  is  approximately  double  the 
amount  exhaled  by  the  lungs.  Contrary  to  the  general  notion,  the  skin 
does  not  excrete  large  quantities  of  deleterious  substances.  In  health  the 
poisons  excreted  by  the  skin  are  very  small  in  amount. 

1  Bohm,  Davidoff  and  Huber — Histology,  p.  397. 

2  Hyde  and  Montgomery— Diseases  of  the  Skin,  p.  46. 


THE  SUDORIPAROUS  OR  COIL  GLANDS  29 

Vicarious  Functions  of  the  Skin.  There  is  a  great  similarity  in  the  struc- 
ture of  the  tubules  and  glomeruli  of  the  kidney  to  the  coil  glands  of  the 
skin  and  their  vascular  tufts.  This  very  similarity  in  structure  suggests  a 
similarity  in  function.  The  perspiration  and  urine  are  both  excretions  and, 
to  a  great  extent  may  replace  each  other.  In  disease,  this  fact  becomes 
very  evident.  When  the  kidneys  become  incompetent  to  excrete  certain 
wastes  these  are  often  found  in  the  sweat  and,  vice  versa,  when  perspira- 
tion is  interfered  with,  more  work  is  thrown  on  the  kidneys.  In  warm 
weather,  excessive  perspiration  occurs,  while  the  urine  is  scanty.  In  cold 
weather  the  perspiration  decreases  and  the  urine  increases  in  amount. 

Urea,  normal  in  the  urine  to  the  extent  of  about  2  per  cent,  is  found  in 
normal  perspiration  to  the  extent  of  0.1  to  0.2  per  cent.  Schottein,  in  cer- 
tain cases  of  the  uremia  of  cholera,  saw  the  whole  body  covered  with  a 
thin  white  crystalline  layer  of  urea.3  In  cases  of  pyemia,  where  the  sta- 
phylococcus  albus  was  present  in  the  blood,  the  sweat  induced  by  packs  has 
shown  abundance  of  the  staphylococcus.  The  same  is  true  of  many  other 
diseases  in  which  there  are  germs  in  the  blood  (bacteriemia),  the  kidneys 
also  excreting  the  germs.  Bouchard 4  has  called  particular  attention  to  the 
cutaneous  eruptions  which  accompany  auto-intoxication,  especially  with  a 
dilated  stomach,  or  after  eating  mussels,  shell-fish,  etc.,  as  being  due  to 
ptomaines  eliminated  through  the  skin.  In  some  forms  of  auto-intoxication, 
various  poisons  excreted  by  the  skin  may  be  appreciated  by  their  odors. 
The  special  cdors  about  prisons  and  asylums  are  doubtless  more  or  less  due 
to  the  volatile  poisons  of  faulty  nutrition  which  the  skin  exhales.  In  cases 
of  jaundice,  bile  pigments  are  found  in  the  sweat  so  that  sheets  and  bed- 
ding are  stained  by  it.  Sugar  may  be  found  in  the  sweat  of  diabetics  and 
in  the  sweat  of  cases  of  forced  glycosuria. 

Dr.  Herbert  U.  Williams  of  Buffalo  has  recently  5  shown  that  in  chronic 
nephritis  the  sweat  glands  are  extensively  altered  in  structure.  He  exam- 
ined skin  from  various  parts  in  seventy  cases  of  chronic  nephritis  and  found 
a  variety  of  conditions  including  desquamation  of  the  epithelium,  cystic 
dilatation  of  the  tubules,  atrophy  of  the  tubules,  and  cast- like  material  in  the 
tubules.  In  fourteen  cases,  arteriosclerosis  of  the  arteries  of  the  skin  was 
present.  In  some  cases,  hypertrophy  of  the  epithelium  was  observed,  even 
to  the  formation  of  two  or  three  layers  of  cells.  Dr.  Williams  states  that 
these  studies  were  undertaken  because,  from  the  earliest  ages,  faith  has 
been  placed  in  the  efficacy  of  active  skin  excretion  in  cases  of  nephritis. 

Summary  of  Perspiratory  Influences 

Factors  which  govern  perspiration: — 

1.  Degree  of  internal  or  external  heat. 

2.  Amount  of  water  in  the  body. 

3.  Amount  of  blood  in  the  skin. 

4.  Specific    stimulation    of   secretory    (sweat)  nerves,  as  by  electricity, 
shock  (as  cold  sweat  of  fright,  etc.),  drugs. 

3  Baruch— Principles  and  Practice  of  Hydrotherapy,  p.  26. 

4  Auto-intoxication  in  Disease,  pp.  20,  162. 

5  Journal  of  American  Medical  Association,  April  17,  1909.  p.  1276. 


30  ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

Conditions  that  give  rise  to  increase  of  perspiration: — 

1.  Applications  of  heat,  as  hot  air,  hot  water,  steam,  light,  etc. 

2.  Water  drinking,  especially  of  hot  water. 

3.  Exercise. 

4.  Mechanical  irritation,  as  friction  or  percussion. 

5.  Diaphoretic  drugs. 

Conditions  that  decrease  perspiration: — 

1.  Chilling  or  cold  applications. 

2.  Excretion  of  large  amounts  of  water  by  the  kidneys  or  bowels. 

3.  Certain  drugs,  as  atropine. 

4.  Local  application  of  astringents,  or  cooling  preparations,  as  alcohol, 
vinegar,  talcum  powder,  etc. 

The  facts  listed  in  the  above  outline  are  perhaps  too  evident  as  matters 
of  every-day  experience  to  need  comment.  In  practice,  we  usually  combine 
two  or  more  of  these  measures  in  order  to  secure  quicker  and  better  results. 
For  example,  the  drinking  of  cold  water  before  and  during  the  electric  light 
bath  greatly  enhances  its  results.  The  drinking  of  hot  lemonade  in  con- 
junction with  hot  packs,  vapor  or  Russian  baths,  likewise  gives  quicker 
results.  Heat  applied  to  the  skin  not  only  increases  the  blood  about  the 
coil  glands,  but  also  stimulates,  directly,  the  secreting  cells.  Cold,  applied 
to  the  skin,  causes  a  decrease  in  the  amount  of  the  blood  in  the  skin  and  so 
lessens  the  available  fluid  which  the  sweat  glands  utilize  for  secretion. 

It  has  been  shown  that  drugs  having  a  specific  action  upon  the  sweat 
glands,  cause  alterations  in  the  structure  of  the  secreting  cells,  thus  prov- 
ing detrimental  to  their  healthy  activity. 

The  Sebaceous  Glands 

The  sebaceous  glands  are  sacciform  in  shape,  found  in  connection  with  the 
hairs  of  the  skin  and  pouring  their  secretion  into  the  follicles  of  the  hair  and 
lanugo.  The  oil  or  sebum  is  produced  by  fatty  degeneration  of  the  gland 
cells  themselves;  more  cells  being  produced  next  the  basement  membrane 
to  take  their  place.  It  is  designed  to  oil  the  hair  and  skin.  The  glands  are 
situated  next  the  hair  follicle,  between  it  and  the  piliary  muscle.  Heat 
softens  the  oil  in  the  glands,  and  thereby  brings  about  its  extrusion.  Oil 
is  a  non-conductor  of  heat.  Covering  the  skin  with  oil  hinders  both  the  eli- 
mination of  heat  where  the  surrounding  atmosphere  is  cold  and  the  absorp- 
tion of  heat  where  the  atmosphere  is  heated. 

Absorption  by  the  Skin 

We  are  not  greatly  concerned  in  hydrotherapy  with  the  absorptive  powers 
of  the  skin.  Oily  substances  are  most  readily  absorbed,  watery  solutions 
not  at  all.  Absorption  of  oily  substances,  alcoholic  or  ethereal  solutions  is 
greater  after  a  warm  bath  and  cleansing  of  the  skin,  since  the  sweat  pores 
are  then  open  and  the  increased  circulation  favors  absorption-. 

Guy    Hinsdale  fi  gives  an  excellent  summary  of  the  subject  of  cutaneous 

(>     Hydrotherapy,  p.  21. 


THE  SEBACEOUS  GLANDS  31 

absorption  from  which  we  quote  the  following:— 

"James  Currie,  who  wrote  one  of  the  first  and  best  books  on  hydrother- 
apy,  states  that  there  is  no  increase  of  weight  in  the  bath,  and  while  the 
skin  remains  sound  and  entire  no  absorption  of  solid,  liquid  or  aeriform 
elastic  fluid  takes  place  on  the  surface.  In  the  instances  that  are  supposed 
to  favor  the  contrary  opinion,  it  will  be  found  that  the  article  is  forced 
through  the  epidermis  by  mechanical  pressure,  or  that  the  epidermis  has 
been  previously  destroyed  by  injury  or  disease." 

Roehrig  in  experimenting  with  a  bath  to  which  potassium  iodide  had  been 
added,  found  that  full  immersion  in  this  for  three  quarters  of  an  hour  gave 
rise  to  no  iodine  in  the  urine.  Negative  results  have  also  been  obtained  by 
a  number  of  other  observers  using  various  soluble  substances.  Substances 
causing  injury  to  the  skin  may  be  absorbed,  also  ethereal  solutions  of  certain 
alkaloids,  but  R.  Winternitz  found  no  evidence  of  the  entrance  of  these 
substances  from  watery  solutions. 

One  must,  therefore,  conclude  that  the  mineral  constituents  of  water — 
other  than  strong  salines  and  gaseous  constituents — have  no  effect  whatever 
upon  the  human  system  when  applied  to  the  unbroken  skin.  Hinsdale  makes 
a  very  apt  statement  of  the  case,  "We  are  thus  forced  to  the  conclusion  pre- 
viously enunciated, —that  the  mineral  waters,  the  analysis  of  which  are 
quoted  with  such  particular  exactitude  unto  the  third  or  fourth  decimal 
place  of  grains  per  gallon,  are  neither  more  or  less  efficacious  on  that  account. 

Cutaneous  Respiration 

To  a  limited  extent,  the  skin  acts  as  a  respiratory  organ  when  the  tem- 
perature is  above  85°  F.  About  0.5  per  cent  of  the  total  gaseous  exchange 
of  the  body  occurs  in  this  manner.  The  amount  of  CO2  exhaled  at  91.4°  F. 
may  be  doubled  at  93°  F.,  increasing  in  about  the  same  ratio  as  the  watery 
excretion.  Hot,  moist  applications  to  the  skin  increase  the  elimination  of 
COa,  since  diffusion  of  gases  is  hastened  by  the  moistening  of  the  surface 
and  the  larger  amount  of  blood  brought  to  the  skin.  It  is  said  that,  in  dis- 
eases of  the  heart  and  lungs,  where  there  is  diminished  excretion  of  CCte  in 
the  expired  air,  cutaneous  exhalation  is  increased.  In  asthmatic  dyspnoea 
when  the  skin  becomes  flushed  and  perspiration  free,  the  dyspnoea  is  some- 
what relieved.  General  perspiration  produced  by  hot  applications  also  re- 
lieves dyspnoea. 

The  Skin  a  Heat  Regulator 

This  will  be  considered  again  under  the  subject  of  Heat  Regulation.  The 
skin  itself  takes  part  in  heat  loss  only,  although  through  nerve  connection, 
it  is  one  of  the  most  important  means  in  controlling  heat  production.  "The 
loss  of  heat  by  the  skin  amounts  to  about  77  per  cent  of  the  total  heat  loss. " 
It  is  therefore  the  most  important  factor  in  the  elimination  of  heat.  The 
regulation  of  heat  loss  by  the  skin  is  accomplished  by  variations  in  the 
amount  of  heat  radiation  and  evaporation  of  sweat. 

It  will  be  seen  that  heat  applied  to  the  skin  increases  heat  loss  in  two 
ways:  first,  by  dilating  the  surface  vessels  and  quickening  cutaneous  circu- 

7    Starling — Human  Physiology,  p.  505. 


32  ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

lation,  thus  increasing  heat  radiation  and  convection;  second,  by  inducing 
free  perspiration  and  the  consequent  loss  of  heat  by  evaporation.  Conversely, 
cold  applied  to  the  skin  decreases  heat  loss  by  driving  the  blood  inward  and 
checking  perspiration. 

It  is  chiefly  through  the  temperature  nerves  of  the  skin  that  this  organ 
influences  heat  production.  So  profound  is  this  influence  that  extensive 
burns,  covering  more  than  two-thirds  of  the  body  are  fatal  through  destruct- 
ion of  the  sensory  nerve  terminals.  Not  only  is  heat  elimination  interfered 
with,  but  metabolism  becomes  excessive  and  heat  production  is  immensely 
increased.  Internal  congestion  and  inflammations  result,  with  a  fatal  termi- 
nation. 

After  a  drunken  debauch,  the  unfortunate  victim  is  in  great  danger  from 
exposure  to  cold,  because  the  sensibility  of  the  nerves  is  temporarily  de- 
stroyed, so  that  the  heat  regulating  centers  are  not  apprised  of  the  danger. 
The  boy  who  died  from  gilding  of  the  skin,  to  represent  an  angel,  is  an  exam- 
ple of  the  disturbance  of  the  heat  mechanism  due  to  interference  with  the 
regulatory  functions  of  the  skin.  After  varnishing  of  the  skin,  the  tempera- 
ture at  first  rises  and  then  falls,  accompanied  by  symptoms  of  poisoning  due 
to  the  defective  oxidation. 

Nerves  of  the  Skin 

We  have  already  considered  the  secretory  and  vasomotor  nerves  of  the 
skin.  The  third  set  of  cutaneous  nerves  of  importance  in  hydrotherapy  are 
those  already  mentioned  as  forming  the  connection  by  which  the  skin  regu- 
lates heat  production  and  loss,  viz.,  temperature  nerves.  These  nerves  are 
not  uniformly  distributed  in  the  skin.  They  are  more  numerous  in  certain 
localities  than  in  others  and  where  more  numerous,  the  temperature  sense 
is  more  acute,  such  as  in  the  tips  of  the  fingers,  the  cheeks  and  backs  of  the 
hands.  These  are  the  parts  we  instinctively  use  to  test  the  safety  of  hot 
water  bottles  and  other  hot  applications. 

The  recognition  of  heat  is  confined  to  the  "hot  spots"  and  that  of  cold  to 
the  "cold  spots,"  as  can  readily  be  proven  by  experiment.  Lightly  resting 
the  point  of  the  pencil  on  the  skin  will  produce  a  sensation  of  heat  or  cold 
according  as  it  rests  on  a  hot  spot  or  cold  spot.  The  two  sensations  are 
appreciated  by  different  end  organs  and  travel  by  different  fibers. 

Applications  to  certain  localities  produce  more  intense  temperature  sensa- 
tions than  to  others.  Applications  to  a  large  area  produce  a  greater  inten- 
sity of  sensation  than  applications  to  a  smaller  area.  These  facts  are  utili- 
zed in  controlling  the  circulation  reflexly  and  mechanically  (q.  v.).  The 
temperature  sense  is  more  acute  when  the  skin  is  warm  or  after  warm  appli- 
cations. This  fact  is  utilized  to  prepare  the  body  for  cold  applications,  so 
that  the  reaction  will  be  greater  and  appear  more  promptly.  As  has  been 
mentioned,  the  temperature  of  the  skin  is  the  zero  of  the  temperature  sense. 

The  skin  contains  also  the  end  organs  of  tactile  sensation.  They  are  more 
numerous  in  certain  localities  than  in  others,  as  are  the  temperature  nerves, 
and  likewise  serve  to  make  the  connection  by  which  cutaneous  applications 
influence  internal  parts. 


CHAPTER    VI 
THE  CIRCULATION— REFLEX  EFFECTS 


During  health,  there  are  vasomotor  influences  constantly  playing  upon 
the  arteries  in  all  parts  of  the  body.  These  influences  hold  the  vessels  in 
"tone,"  i.  e.,  control  the  rhythmic  oscillations  in  calibre,  so  that  blood  pres- 
sure is  maintained.  These  influences  seem  to  emanate  from  a  vasomotor 
center  which  is  located  in  the  medulla  oblongata  in  the  floor  of  the  fourth 
ventricle.  "Irritation  of  this  center  causes  contraction  of  all  the  arteries 
and,  in  consequence,  increase  in  arterial  blood  pressure."  "Paralysis  of  the 
center  causes  relaxation  and  dilatation  of  all  the  arteries,  with  enormous 
reduction  in  blood  pressure.  Under  normal  conditions,  the  vasomotor  center 
is  in  a  state  of  moderate  tonic  excitation."  1  While  this  center  exercises 
a  controlling  influence  overall,  it  is  not  the  only  vasomotor  centre.  "Centers 
for  the  vascular  nerves,  both  vasomotor  and  vasodilator,  are  distributed 
throughout  the  entire  spinal  axis."  "They  can  be  excited  reflexly,  although 
they  are  subordinated  to  the  dominating  centers  in  the  medulla  oblongata. "  2 
"It  is  obvious  that  such  a  mechanism  as  that  described.  .  .  .  is  susceptible 
of  reflex  stimulation  through  sensory  nerves,  and  according  to  our  general 
knowledge  we  should  suppose  that  a  tonic  centre  of  this  kind  may  have  its 
tonicity  increased  (excitation)  or  decreased  (inhibition)."3  It  is  to  the  reflex 
stimulation  of  these  centres  that  we  now  wish  to  turn  our  attention,  for 
through  this  channel,  hydrotherapy  produces  some  of  its  most  important 
effects. 

Maximilian  Schuller,4  in  experimenting  on  trephined  rabbits,  observed 
that  severing  single  nerve  trunks  on  one  side  of  the  animal  produced  a  dis- 
tinct (though  transient)  dilatation  of  the  pial  vessels  on  the  corresponding 
side,  thus  proving  that  the  blood  vessels  of  the  piamater  are  held  in  steady 
tone  by  continuous  excitation  from  the  cutaneous  sensory  nerves.  This  re- 
sult was  observed  only  on  the  side  of  the  severed  nerve  ao  that  it  could  not 
have  been  due  to  shock  or  pain. 

"Naumann  has  demonstrated  clearly  that  the  effects  of  external  irritants 
upon  the  circulation  within  the  body  are  really  reflex.  He  separated  the  head 
of  a  frog  from  the  body,  leaving  them  connected  by  the  medulla  oblongata, 
only.  He  next  severed  one  leg,  after  preventing  loss  of  blood  by  ty- 
ing the  vessels,  so  as  to  leave  it  connected  with  the  body  by  the  sciatic 
nerve.  Now  he  applied  thermal,  chemical  and  electric  stimuli  to  the  foot  of 

1  Landois— Physiology  1905,  p.  762. 

2  Landois— Physiology,  p.  735;  see  also  Howell-  Physiology,  p.  564;  and  Foster— Physiology 
1898,  p.  285. 

3  Howell— Physiology,  p.  560. 

4  Deutches  Archiv  fur  klinische  Medicin,  No.  4,  1874. 


34  THE  CIRCULATION— REFLEX  EFFECTS 

the  partially  severed  leg:,  while  he  observed,  under  the  microscope,  the 
mesentery  of  the  frog.  Shortly  after  gentle  irritation  of  the  peripheral  end- 
ings of  the  sciatic  nerve  in  the  foot,  the  circulation  in  the  vascular  network 
of  the  luna^s  and  mesentery  was  accelerated,  and  resumed  the  former  condi- 
tion slowly  after  the  withdrawal  of  the  irritant.  A  more  severe  irritation 
produced  retardation  of  the  flow,  and  even  stasis  occurred,  as  if  the  heart 
had  become  temporarily  paralyzed.  A  strong  irritant  produced  dilatation;  a 
feeble  one,  constriction  of  the  vessels.  The  effect  of  these  peripheral  irri- 
tations upon  the  heart  was  also  noted.  A  strong  irritation  of  the  skin  weak- 
ened its  circulation;  a  feeble  irritant  strenghtened  it.  As  there  was  no  pos- 
sible vascular  or  nerve  channel  from  the  part  irritated  to  the  part  thus  visi- 
bly affected,  the  conclusion  is  inevitable  that  the  effect  is  entirely  reflex. 
Hot  water  acted  precisely  as  other  irritants."  5  These  experiments  also 
prove  that  there  are  two  reflex  means  by  which  the  circulation  may  be 
influenced,  viz.,  reflex  stimulation  of  the  vasomotors,  producing  changes  in 
vascular  calibre,  and  reflex  stimulation  of  the  heart  muscle  itself.  Another 
point,  brought  out  by  the  experiments  of  Roehrig,  is  that  when  intense 
cutaneous  irritants  produce  considerable  slowing  of  the  heart  beat,  they  also 
increase  its  force.  This  is  the  effect  of  a  prolonged  cold  application, 
whether  general,  as  with  the  Brand  bath,  or  local,  as  with  the  ice  bag  to 
the  precordia. 

Reflex  Areas 

The  fact  of  reflex  stimulation  being  established,  we  may  next  consider 
the  location  (topography)  of  the  various  reflex  areas.  While  the  brain, 
heart  and  other  viscera  may  be  reflexly  influenced  by  stimuli  applied  to  many 
different  cutaneous  areas,  some  even  very  remote  from  these  organs,  the 
maximum  effects  are  produced  by  stimulation  of  certain  very  definite  and 
well  recognized  areas.  In  general,  it  may  be  said  that  the  skin  over  an  organ 
is  reflexly  related  with  that  organ.  In  most  cases,  it  is  not  difficult  to  trace 
the  nerve  connection. 

"In  general,  the  skin  overlying  an  organ  is  reflexly  associated  with  it, 
which  is  the  reason  why  applications  of  electricity  over  an  organ  usually 
influence  it,  and  not  altogether  because  the  current  is  passed  through  the 
organ.  When  these  areas  are  studied  comparatively,  it  is  noted  that  they 
are  practically  the  same  as  those  regions  pointed  out  as  showing  reflex  pain, 
which  would  suggest  a  nervous  path  from  the  organ  to  the  skin  and  from 
the  skin  to  the  organ,  the  terminations  of  which  are  in  the  same  visceral 
and  cutaneous  fields."6  So  definite  and  circumscribed  are  some  of  these 
areas  that  B.  G.  A.  Moynihan  has  frequently  observed,  in  cases  of  duodenal 
ulcer,  a  small  hypersensitive  spot  in  the  skin  covering  the  abdomen,  directly 
over  the  ulcerated  area.  It  is  no  larger  that  a  six-pence  and  he  attaches 
much  value  to  this  phenomenon  in  differentiating  ulcer.  ' 

It  must  not,  however,  be  supposed  that  the  reflex  path  from  the  viscera 

5     Baruch — Principles  and  Practice  of  Hydrotherapy,  p.  37. 

6.  S.  D.  Ludlum— The  Relationship  between  the  Spinal  Cord,  the  Sympathetic  System  and 
Therapeutic  Measures— Journal  of  American  Medical  Association,  May  2,  1908,  pp.  1401 — 1405. 

7  W.  D.  Haines— The  Differential  Diagnosis  of  Duodenal  Ulcer  and  Gall  Stones— Surgery, 
Gynecology  and  Obstetrics— March,  1908,  p.  279. 


PLATE  I 
THE  INNERVATION  OF  THE  HEART  (POWELL) 


REFLEX  ARC 


85 


to  the  skin  over  which  pain  is  referred  is  the  same  path  as  that  utilized  in 
therapeutics  for  reflex  effects  upon  the  internal  organs.  Nor  are  the  skin 
areas  to  which  pain  is  referred  always  the  same  areas  that  should  be  util- 
ized to  influence  reflexly  the  organ  in  which  the  cause  of  pain  is  located. 
For  example  in  the  case  of  liver  and  gall-bladder  disease  there  is  frequently 
a  pain  in  the  region  of  the  right  shoulder  or  shoulder  blade,  but  it  is  not  to 
this  region  that  applications  are  made  to  relieve  distress  due  to  hepatic  or 
biliary  affections. 


The  various  cutaneous  areas  to  which 
ceral  disease  is  referred,  are  spoken  of 
as  the  dermatomes  of  Head.  They  are 
in  some  cases  of  considerable  service  in 
diagnosis  and  are  sometimes  serviceable 
as  a  guide  in  the  placing  of  therapeutic 
applications.  They  can  not,  however, 
be  implicitly  relied  upon  for  either  pur- 
pose. Relative  to  this  unreliability 
Abrams8  says:  "The  elicitation  of  the 
dermatomes  of  Head  is  a  tedious  method 
of  examination  and  not  always"  accom- 
panied by  satisfactory  results  for  the 
reason  that  a  great  amount  of  experi- 
ence is  necessary.  Alsberg  in  the  ex- 
amination of  two  hundred  women  (with 
gynecological  affections)  found  cutane- 
ous areas  of  hyperalgesia  in  only  seven- 
teen, ten  of  whom  were  hysterical. 
Therefore,  he  could  attribute  no  diag- 
nostic import  to  the  zones  in  question 
beyond  commenting  on  the  fact  that 
hysterical  stigmata  must  be  excluded 
before  the  zones  of  hyperalgesia  could 
be  regarded  as  trustworthy."  Diagno- 
sis and  therapeutics  based  on  para-spinal 
tenderness  must  therefore  be  of  a  highly 
imaginative  character  and  especially  so 
when  approached  from  the  standpoint  of 
a  prejudgment  as  to  the  causes  of  dis- 
ease and  consequently  its  treatment. 

The  law  that  the  skin  over  an  organ 
is  reflexly  related  with  that  organ  may 
be  recognized  as  an  amplification  of 
Hilton's  law, — TJie  principle  nerve  to  a 
joint  not  only  supplies  the  articular 
surfaces,  but  also  some  of  the  main 
•muscles  that  move  that  joint  and  the 
skin  over  these  muscles. 9  In  the  case 
of  the  viscera,  however,  the  deeper 
part  of  the  reflex  arc  consists  of  a 
sympathetic  neuron. 

The  reflex  arc  consists  pf  several 
parts  (Fig.  9  and  Plate  II).  In  gen- 
eral, the  following  is  the  path  taken  by 

8  Spondylotherapy,  p.  71. 

9  Treves— Applied  Anatomy  1901,  p.  209. 


the  pain  or  tenderness  due  to  vis- 


Fig.  9.  Diagram  to  show  path 
of  vasoconstrictor  fibers  from  vaso- 
constrictor center  to  the  blood  ves- 
sels and  the  path  for  reflex  stimu- 
lation, v.  c.  The  vasoconstric- 
tor center;  1,  the  central  neuron 
of  the  vasoconstrictor  path;  2,  the 
the  spinal  neuron  (preganglionic); 
3,  the  sympathetic  neuron  (gang- 
lionic);  a,  the  arteriole;  4,  the 
sensory  fibers  of  the  posterior 
root  connecting  by  collaterals  with 
the  vasoconstrictor  center  and 
subcenters;  5,  fiber  from  cortical 
cell  acting  upon  the  vasoconstric- 
tor center.  (Howell) 


36  THE  CIRCULATION— REFLEX  EFFECTS 

a  stimulus  arising  in  the  skin  from  a  thermic  application  and  traced  as  a  reflex 
stimulus  to  the  organ  underlying  the  skin  surface  treated.  From  the  skin, 
it  is  conveyed  by  a  sensory  (temperature)  nerve  along  a  nerve  trunk  to  the 
posterior  root  of  the  spinal  nerve;  entering  the  posterior  root  ganglion, 
where  the  fibre  is  seen  to  the  distal  axon  of  a  T  cell;  it  passes  on  through 
the  central  axon  of  the  T  cell  into  the  posterior  side  of  the  spinal  cord.  On 
entering  the  cord,  the  fibre  immediately  divides  into  an  ascending  and  a 
descending  branch,  both  located  in  the  posterior  white  columns  and  which 
give  off  collaterals  to  the  gray  matter. 10  The  ones  we  are  concerned  with 
end  in  tufts  about  the  cells  of  the  column  of  Clark.  According  to  Starling,11 
the  vasomotor  center  in  the  medulla  corresponds  in  position  to  the  column 
of  Clark  which  is  doubtless  that  which  represents  the  vasomotor  center 
throughout  the  rest  of  the  cord.  From  these  cells,  axons  pass  either 
into  Gower's  tract  and  end  in  the  cerebellum,  12  or  pass  out  with  the  anterior 
root,  and  through  the  white  ramus  to  the  ganglion  of  the  lateral  sympa- 
thetic chain.  13  Passing  directly  through  this,  or  up  or  down  through  an 
adjacent  ganglion,  they  end  in  a  peripheral  ganglion  from  which  the  viscus 
is  supplied. 

"The  fibers  of  the  white  ramus  which  pass  through  the  ganglion  and  go 
to  the  periphery  are  known  as  the  splanchnic  efferent  fibers,  and  constitute 
the  secretory  fibers  of  the  splanchnic  glands  and  the  motor  fibers  of  the 
muscular  tissue  of  the  splanchnic  blood  vessels  and  viscera."  14 

By  studying  carefully  the  above  reflex  path,  it  will  be  noted  that  a  stimulus 
may  affect  (be  shunted  to)  cells  either  above  or  below  (Fig.  9)  the  level  at 
which  it  enters  the  spinal  cord.  And  again,  the  fiber  that  conveys  the  reflex 
stimulus  to  the  viscera  may  pass  up  or  down  in  the  gangliated  cord.  This 
fact  is  of  importance  in  explaining  why  cutaneous  nerves  are  connected 
reflexly  with  splanchnic  nerve  trunks  not  arising  in  the  same  segment  of 
the  cord.  15 

Of  the  many  reflex  paths,  we  may  pick  out  two  as  serving  to  quite  fully 
illustrate  reflex  effects.  First,  let  us  study  the  reflex  arc  concerned  in  the 
effect  produced  by  an  ice  bag  applied  to  the  precordial  region.  And  second, 
the  arc  concerned  in  the  reflex  between  the  skin  of  the  epigastrium  and  the 
stomach. 

The  Heart.  Before  considering  the  reflex  arc,  we  should  understand  that 
the  heart  is  supplied  with  nerves  from  two  sources.  (Plate  I.)  First, 
through  the  vagus  nerve  (fibers  of  accessory  part  of  the  spinal  accessory 
nerve)  with  inhibitory  fibers,  i.  e.,  fibers  which  when  stimulated,  slow  the 
heart  beat  and  increase  its  force.  Second,  by  accelerator  fibers,  which 
when  stimulated,  increase  the  rapidity  of  the  heart  beat  through  the  cardiac 

10  Whitakei — Anatomy  of  the  Brain  and  Spinal  Cord,  p.  38. 

11  Physiology,  p.  259. 

12  Ludlum — Journal  of  American  Medical  Association,  May  2,  1908,  p.  1403. 

13  Whitaker— Ibid.,  p.  39. 

14  Gray's  Anatomy  1905,  p.  1071. 

15  Each  segment  of  the  spinal  cord  may  be  regarded  as  a  unit  and  possessed  of  sensory,  motor, 
vasomotor,  secretory  and  trophic  functions.    The  roots  and  peripheral  nerves  derived  from  a 
given  segment  are  an  integral  part  of  that  segment.    The  connection  of  one  segment  with 
another  does  not  interfere  with  this  conception. 


PLATE   II 

REFLEX  ARC  FROM  SKIN  TO  HEART 


1.— Third  intercostal  nerve. 
2.— Anterior  root  of  spinal  nerve. 
3.— Posterior  root  of  spinal  nerve. 
4.— Posterior  root  ganglion. 
5.— Inferior  cardiac  nerve. 

6  — Gangliated  cord  of  lateral  sympa- 
thetic chain,  a— Inferior  cervical 
jranglion.  b,  c,  d,  e— 1st,  2nd,  3rd 
and  4th  thoracic  ganglia. 

7.— White  ramus  communicans. 


8. — Afferent  sensory  nerve  of  temper- 
ature. 

9.— The  same  in  the  spinal  cord   (pos- 
terior white  columns) . 
10. — Collateral  branches  of  No.  9. 
11. — Direct  cerebellar  tract. 
12. — Gower's  tract. 
13.— Clark's  column. 
14.—  Level  of  3rd  thoracic  segment. 
15.— Skin  of  precordia. 
16.— Heart    with    superficial    cardiac 
plexus. 


REFLEX  ARC  37 

sympathetic  nerves  from  the  inferior  cervical  ganglion.  The  acclerator 
fibers  emerge  from  the  spinal  cord  in  the  anterior  roots  of  the  second,  third 
and  fourth  thoracic  spinal  nerves  and,  according  to  some  authors,  are 
found  also  in  the  first  and  fifth  thoracic  nerves.  16  From  these  spinal  nerves, 
they  pass  to  the  corresponding  sympathetic  ganglia  of  the  lateral  chain, 
through  the  white  rami  communicantes  and  thence  upward  to  the  inferior 
cervical  ganglion. 

The  ice  bag  applied  to  the  precordia  covers  the  skin  supplied  by  the  second, 
third,  fourth  and  fifth  thoracic  nerves.  The  stimulus  (of  a  depressing  nature) 
produced  by  the  cold  application  is  carried  to  the  spinal  cord  by  the  nerve 
fibers  of  these  thoracic  nerves  which  end  in  the  same  segments  in  which  the 
accelerator  fibers  of  the  heart  arise.  (Plate  II)  The  reflex  stimulus  produced 
by  the  afferent  impulse  (sensation  of  cold)  upon  the  cells  in  the  column  of 
Clark  is  conveyed  outward  by  the  axons  of  these  cells  through  the  anterior 
roots  and  by  way  of  the  white  rami  reaches  the  sympathetic  ganglia  through 
which  they  pass  to  the  inferior  cervical  ganglion,  and  thence,  by  the  inferior 
(sympathetic)  cardiac  nerve  to  the  superficial  cardiac  plexus  and  the  heart 
muscle.  The  accelerator  mechanism  being  depressed,  the  heart  beats  slower 
and  with  greater  force  from  the  proportionately  greater  action  of  the  inhibi- 
tory nerves. 

An  ice  bag  over  the  heart  produces  its  action  by  depressing  the  accelera- 
tor (sympathetic)  nerves  and  not  by  stimulating  the  vagus,  as  has  been 
claimed  by  some;  which  latter,  it  will  be  seen,  would  be  impossible  since 
the  prolonged  cold  of  the  ice  bag  exerts  a  depressing  and  not  a  stimulating 
effect  which  must  be  the  case  were  slowing  produced  through  the  vagus. 

The  Stomach.  The  skin  over  the  pit  of  the  stomach  is  supplied  by  the 
seventh  and  eighth  intercostal  nerves. 17  The  great  splanchnic  nerve  is 
formed  by  branches  from  the  thoracic  ganglia  between  the  fifth  or  sixth  and 
the  ninth  or  tenth.  It  terminates  in  the  semilunar  ganglion  of  the  solar 
plexus. 18  From  the  solar  plexus,  (cosliac  part)  fibers  accompany  the  blood 
vessels  to  the  stomach. 

"The  nerves  supplying  the  abdominal  muscles  and  the  skin  are  derived 
from  the  lower  intercostal  nerves  and  are  intimately  connected  with  the 
sympathetic  nerves  supplying  the  abdominal  viscera  through  the  lower 
thoracic  ganglia  from  which  the  splanchnic  nerves  are  derived." 

These  reflex  arcs  may  be  traced  out  in  the  case  of  other  organs  and  areas. 
While  an  application  to  the  skin  over  an  organ  gives  a  maximum  effect, 
applications  to  even  very  distant  areas  may  be  quite  effective.  For  exam- 
ple, hot  applications  to  the  feet  do  not,  under  ordinary  conditions,  influence 
reflexly  the  circulation  of  the  brain.  But  under  conditions  of  vasomotor 
instability,  such  as  that  following  a  sunstroke,  a  hot  foot  bath  may  cause 
congestion  of  the  brain  (personal  observation) . 

16  Howell— Physiology  1908,  p.  542. 

17  Gray's  Anatomy  1905,  p.  997. 

18  Ibid.,  p.  1079. 

19  Ibid.,  p.  997. 


38  THE  CIRCULATION— REFLEX  EFFECTS 

Special  Reflex  Areas 

The  following   are   the  principal  reflex  areas  employed  in  hydrotherapy 
(Fig.  10  after  Kellogg)  :— 

1.  The  skin  areas  of  the  face,  scalp  and  back  of  the  neck  are  reflexly 
related  with  the  brain. 

2.  The  skin  of  the  neck  is  reflexly  related  with  the  pharynx  and  larynx. 

3.  The  back  of  the  neck  is  reflexly  related  with  the  mucous  membrane  of 
the  nose. 

4.  The  skin  of  the  chest  (front,  back  and  sides) ,  dorsal  region  and  shoulders 
has  reflex  relations  with  the  lungs. 

5.  The  precordia  is  in  very  perfect  reflex  relation  with  the  heart  through 
its  accelerator  nerves 

6.  The  hands  are  related  with  the  brain  and  nasal  mucous  membrane. 

7.  The  skin  over  the  lower  right  chest,  with  the  liver. 

8.  The  skin  over  the  lower  left  chest,  with  the  spleen. 

9.  The  skin  over  the  lower  third  of  the  sternum,  with  the  kidneys. 

10.  The  mid-dorsal  spine  (from  fifth  to  seventh  vertebrae)  is  related  with 
the  stomach. 

11.  Lower  dorsal  and  lumbar  spine,  with  the  kidneys  and  intestines. 

12.  The    lower  lumbar  and  sacral  spine,  with  the  pelvic  organs — uterus, 
ovaries,  bladder  and  rectum. 

13.  The  epigastrium,  with  the  stomach. 

14.  The    skin   of   the   entire   abdomen,    especially   that  of  the  umbilical 
region,  is  reflexly  related  with  the   intestines.     The  fact  that  the  pain  of 
colic,  appendicitis,  etc.,  is  referred  to  the  region  of  the  umbilicus  is  an  evi- 
dence of  a  similar  nervous  connection. 

15.  The  lower  abdomen,  including  the  groin  and  upper  inner  surfaces  of 
the  thighs  are  reflexly  related  with  the  pelvic  organs. 

16.  The  skin  of   the   feet    and   legs   is   reflexly   related  with  the  brain, 
lungs  and  pelvic  organs.     This  is  not  as  powerful  a  reflex  area  as  some  others. 

More  practically  stated,  the  circulation,  secretory  and  muscular  activities 
of  the  viscera  may  be  influenced  reflexly  by  applications,  as  follows:— 

1.  The  brain,  by  applications  to  the  head,  face,  back  of  neck,  hands  and 
feet. 

2.  The  nasal  mucous  membrane,  by  applications  to  the  face,  hands  and 
cervical  and  upper  dorsal  spine. 

3.  The  lungs,  by  applications  to  the  chest,  shoulders  and  dorsal  spine. 

4.  The  heart,  by  applications  to  the  precordia  and  upper  dorsal  spine. 

5.  The  stomach,  by  applications  to  the  epigastrium  and  mid-dorsal  spine. 

6.  The  liver,  by  applications  to  the  lower  right  chest  and  the  abdomen. 

7.  The  spleen,  by  applications  to  the  lower  left  chest  and  the  abdomen. 

8.  The  kidneys,  by  applications  to  the  lower  third  of  the  sternum,  lower 
dorsal  and  lumbar  spine. 

9.  The  intestine,  by  applications  to  the  abdomen,  and  lower  dorsal  and 
lumbar  spine. 


Lungs 
Heart 
Kidneys 

Stomach 

Liver 

Spleen 

..  Intestines 


.-.\. 1- Pelvic  Viscera 


Brain 


V  Ovaries  and  Tubes 

I  Brain,  Nasal  Mucou 
'      Membrane  and  Lu 


Lungs 


Brain,  Lungs  and 
Pelvic  Organs 


Fig.  10.     Anterior  Reflex  Areas 


40  THE  CIRCULATION— REFLEX  EFFECTS 

10.  The  bladder,  by  applications '  to  the  lower  abdomen,  inner  surfaces  of 
thighs,  and  the  feet. 

11.  The  uterus,  by  applications  to  the  lumbar  and  sacral  regions,  lower 
abdomen,  inner  surfaces  of  thighs,  breasts,  feet  and  cervix. 

In  the  large  majority  of  cases,  the  ventral  areas  give  stronger  reflex 
effects  than  the  dorsal  areas.  This  is  doubtless  for  the  reason  that,  with  a 
ventral  area,  the  effect  is  concentrated  upon  a  single  organ,  while  in  the  case 
of  a  dorsal  area,  limited  to  the  region  of  the  spine  itself,  the  effect  would 
be  spread  out  over  several  organs,  or  possibly,  the  viscera  of  both  the  chest 
and  abdomen.  "If  an  ice  bag  is  placed  in  contact  with  the  whole  length  of 
the  spine,  the  same  effect  on  the  heart  and  lungs  is  produced  as  that  which 
is  desired  on  the  intestines,  and  the  whole  process  is  negatived,  whereas,  if 
limited  anteriorally  to  the  sixth  segment,  the  effect  is  localized  on  the  abdomi- 
nal viscera."  * 

A  reflex  effect  is  then  an  indirect  effect  produced  through  nerve  connection. 
An  application  to  one  part  of  the  body  which  influences,  through  nerve  con- 
nection, another  part  of  the  body  is  said  to  exert  a  reflex  effect.  Abrams  21 
gives  the  following  definition:  "A  reflex  refers  to  involuntary  production 
of  activity  in  a  part  brought  about  by  conduction  of  a  stimulus  along  an  affer- 
ent (sensory)  nerve  to  the  motor  cells  in  the  cord  or  medulla.  This  stimulus 
is  converted  into  an  impulse  by  the  motor  cells,  which  impulse  is  then  con- 
ducted to  a  part  by  means  of  an  efferent  (motor)  nerve." 

Classes  of  Reflex  Effects 

Having  established  the  fact  of  reflex  action  and  traced  out  some  of  these 
reflex  arcs,  let  us  now  consider  the  nature  of  the  various  reflex  effects.  We 
have  already  noted  that  there  are  three  kinds  of  fibers  which  make  up  the 
splanchnic  efferents:  viz.,  the  secretory,  viscero-motor  and  vasomotor. 
These  are  also  the  chief  functions  of  the  various  viscera  and  by  these,  meta- 
bolism itself  and  all  other  functions  are  controlled.  "By  applying  heat  or 
cold  or  other  stimuli  to  the  segment  of  the  skin  whose  endings  are  in  a  seg- 
ment in  which  arise  viscero-motor,  vasomotor  or  other  activities,  we  can 
reflexly  affect  the  organ  supplied  by  these  tracts.  That  this  can  be  done 
has  been  shown  by  the  researches  of  Brown-Sequard  and  others,  .... 
chiefly  through  the  vasomotors.  The  change  may  be  observed  by  heat  and 
cold,  impact  of  water,  hand  pressure,  steady  or  alternated,  electricity, 
mechanical  stimulation  or  other  means,  yet  the  underlying  principle  remains 
the  same.  The  application  of  these  physical  forms  of  therapy  must  be  made 
more  and  more  accurately  to  get  the  best  effect."  K 

There  are  two  general  classes  of  effects  produced  by  these  applications. 
They  may  be  designated  as  pressor  and  depressor,  as  stimulant  and  calma- 
tive, or  excitant  and  sedative.  Because  the  pressor,  stimulant  or  excitant 
effects  are  usually  mild  and  tend  to  restore  to  a  normal  tone,  they  are  fre- 
quently designated  as  tonic. 

20  S.  D.  Ludlum — Journal  American  Medical  Association,  May  2,  1908. 

21  Spondylotherapy,  p.  26. 

22  S.  D.  Ludlum— Ibid.,  pp.  1403,  1405. 


REFLEX  EFFECTS  OF  COLD  41 

Special  Reflex  Effects 

In  general,  the  reflex  effect  of  an  application  is  the  same  as  its  direct 
effect  upon  the  skin.  That  it  may  be  somewhat  less  quantitatively  would  be 
a  natural  result.  The  following  is  a  comparison  of  the  direct  and  reflex 
effects  of  prolonged  cold. 

A  long  (continuous)  local  application  of  cold  decreases  the  vital  activities 
of  the  surface  treated  and  the  internal  part  reflexly  related  therewith. 

1.     Effects  upon  the  part  to  which  the  application  is  applied, — 
a.     The  blood  vessels  of  the  skin  or  mucous  membrane  are  contracted. 


Fig.  11.  Sphygmographic  tracing  of  radial  pulse,  showing 
contraction  of  the  vessels  of  the  forearm  resulting  from  applica- 
tion of  ice  to  bend  of  elbow.  (Kellogg) 


jj  .•'.'-:    TIME  Iff  5ECOND5 


Fig.  12.  Plethysmographic  tracing,  showing  diminution 
in  the  volume,  of  the  forearm  resulting  from  application  of  ice 
to  elbow.  (Kellogg) 

b.  The  cutaneous  sensibility  is  lessened  and  reflex  excitability  is  de- 
creased and  slowed  because  of  this. 

c.  Glandular  activity  is  decreased. 

d.  The  skin  muscles  are  contracted. 
2.     The  reflex  effects,— 

a.     The  blood  vessels  of  the  deep  (internal)  organ  are  contracted  and 

remain  so. 

6.     The  nerve  irritability  of  the  internal  organ  is  lessened. 

c.  The  glandular  activity  of  the  deep  part  is  decreased  and  secretion  is 

lessened. 

d.  The  muscles  of  the  deep  organ  are  caused  to  contract  more  firmly. 


42  THE  CIRCULATION— REFLEX  EFFECTS 

The  reflex  effect  obtains  as  long  as  the  application  is  in  place  and  for  a 
variable  length  of  time  after  its  removal.  The  duration  and  intensity  of 
reflex  effects  depends  upon  the  duration  and  intensity  of  the  application. 
The  vasoconstrictor  effects  of  prolonged  cold  may  not  be  very  marked  in 
health,  but  in  the  case  of  a  congested  organ,  an  ice  bag  applied  to  the  reflex 
area  produces  an  astonishing  result. 

Special  Reflex  Effects  of  Prolonged  Cold. 

1.  Cold  applied  over  the  trunk  of  an  artery    causes   contraction  of  the 
artery  and  its  distal  branches.   (Figs.  11  and  12)     Example,  —ice  bags  applied 
over  the  carotid  arteries   decrease  the  blood  going  to  the  brain  and  head 
generally.     Such  an  application  is  called  a  proximal  application. 

2.  Prolonged  immersion  of  the  hands  in  cold  water  causes  contraction  of 
the  vessels  of  the  brain  and  nasal  mucous  membrane. 

3.  Prolonged  cold  to  the  upper  dorsal  region  causes  contraction  of  the 
vessels  of  the  nasal  mucous  membrane  and  lungs. 

4.  An  ice  bag  applied  to  the  precordia  slows  the  heart  rate,  increases  its 
force,  and  raises  arterial  blood  pressure. 

5.  An  ice  bag  applied  over  the  thyroid  gland  (in  parenchymatous  goitre) 
decreases  its  vascularity  and  lessens  its  glandular  activity. 

6.  Long  cold  applications  to  the  chest,  at  the  back,  front  or  sides,  con- 
tract the  blood  vessels  of  the  lungs,  slow  respiration,  and  increase  its  depth. 

7.  An  ice  bag  to  the  epigastrium  or  mid-dorsal  region  causes  contraction 
of  the  vessels  of  the  stomach  and  lessens  gastric  secretion,  while  the  appli- 
cation continues.  ** 

8.  A  long  cold  application  to  the  pelvis,  groin  or  inner   surface  of  the 
thighs  contracts  the  blood  vessels  of  the  pelvic  organs. 

9.  A  long  cold  sitz  bath  causes  firm  contraction  of  the  uterine  muscle, 
thereby  reducing  subinvolution. 

10.  A  much   prolonged,    very   cold  application  to  the  sacrum,  such  as  a 
large  ice  bag.  dilates  the  blood  vessels  of  the  uterus,  thus  increasing  men- 
strual flow  and  inhibiting  pain.     This  paralyses  the  reflex.    The  posterior  re- 
flex area  being  in  less  perfect  relation  with  the  uterus  than  the   anterior 
area,  makes  this  possible. 

11.  Long  cold  applications  to  the  face,  forehead,    scalp  and  back  of  the 
neck  cause  contraction  of  the  blood  vessels  of  the  brain. 

12.  An  ice  bag  to  the  lower  third  of  the  sternum  or  over  the  lower  dorsal 
and  upper  lumbar  regions  causes  contraction  of  the  blood  vessels  of  the  kid- 
ney. 

13.  Ice  bags  applied  to  the  sides  of  the  neck  just  below  the  jaw  contract 
the  blood  vessels  of  the  pharynx. 

Special  Reflex  Effects  of  Short  Cold.  Short  cold  applications  to  a  reflex 
area  produce  tonic  and  stimulating  effects  in  the  deep  part  by  virtue  of  the 
reaction  which  soon  follows. 

1.  Short  cold  applications  to  the  face  and  head  stimulate  mental  activity. 

2.  A  short  cold  application  to  the  chest,  as  a  cold  rub,  friction  or  cold 

23    See  experiments  by  Kasanski  in  chapter  on  Peptogenic  Effects. 


SPECIAL  REFLEX  EFFECTS  43 

douche  at  first  increases  the  respiration  rate.    Soon  it  results  in  deeper  res- 
piration with  a  somewhat  slowed  rate. 

3.  A  cold  douche  to  the  precordia  or  slapping  the  chest  with  a  cold  towel 
increases  both  the  heart  rate  and  force.    After  the  cessation  of  the  applica- 
tion, the  rate  decreases  while  the  force  remains  increased. 

4.  A  short  very  cold  percussion  douche  to  a  reflex  area  causes  active  di- 
latation of  the  blood  vessels  in  the  related  viscera, — as  a  short  cold  douche  to 
the  sacrum  or  feet  causes  dilatation  of  the  vessels  of  the  uterus. 

5.  Short    or    moderately   prolonged   cold    applications    to    the    breasts 
cause  vigorous  contractions  of  the  uterus — of  use  in  inertia  uteri. 

6.  Short  very  cold  applications  to  abdomen,  hands  or  feet  cause  contrac- 
tion of  the  muscles  of  the  bladder,  bowels  and  uterus. 

7.  A  short  cold  douche  or  ice  bag  intermittently  to  the  lower  third  of  the 
sternum  causes  increased  renal  secretion. 

8.  A  very  short  cold  douche  to  the  liver  causes  active  dilatation  of  its  ves- 
sels and  increases  its  glandular  activity. 

9.  The  reaction  from  a  moderately  prolonged  cold  application  to  the  epi- 
gastrium causes  increased  gastric  secretion.  ^ 

Reflex  Effects  of  Hot  Applications. 

1.  A  very  much  prolonged  hot  application  to  a  reflex  area  produces  pas- 
sive dilatation  of  the  blood  vessels  of  the  related  organ. 

2.  Long  hot  applications  to  the  precordia  and  to  many  other  parts  increase 
the  heart  rate,  decrease  its  force  and  lower  blood  pressure. 

3.  Hot  moist  applications  to  the  chest  facilitate  respiration  and  expectora- 
tion. 

4.  Long,  moderately  hot  applications  over  the  stomach  after  meals  in- 
crease gastric  secretion  and  hasten  digestion.     The  same,  if  given  before  a 
meal,  decrease  gastric  secretion  because  of  the  atonic  reaction  which  ensues. 

5.  Prolonged  hot  applications  to  the  abdomen  lessen  peristalsis. 

6.  Prolonged  hot  applications  to  the  pelvis,  as  a  fomentation,  pack  orsitz- 
bath,  relax  the  muscles  of  the  bladder,  rectum  and  uterus  and  dilate  their 
blood  vessels,  increasing  the  menstrual  flow. 

7.  A  large  hot  application  to  the  trunk,  as  a  hot  pack,  in  biliary  or  renal 
colic,  relaxes  the  muscles  of  the  bile  ducts,  gall  bladder  or  ureters  and  aids 
in  relieving  the  pain  due  to  spasm  of  these  muscles. 


CHAPTER  VII 


THE  CIRCULATION-HYDROSTATIC  EFFECTS 


Not  all  of  the  circulatory  effects  occurring  in  organs  and  parts  distant  from 
an  application  can  be  explained  by  reflex  action.  In  fact,  many  of  the  effects 
produced  by  hydriatic  applications  are  quite  the  contrary  to  what  we  might 
expect  were  the  results  due  alone  to  reflex  stimulation.  When  Schuller,  in 
the  course  of  his  experiments  upon  trephined  rabbits,  placed  a  sponge 
dipped  in  cold  water  (52°  F)  upon  the  trunk  of  a  peripheral  nerve,  he  obser- 
ved narrowing  of  the  pial  vessels.  This  was  the  same  result  as  that  obtained 
by  pieces  of  ice  applied  to  the  dura.  In  both,  there  was  vasoconstriction 
of  the  vessels  of  the  pia;  and  we  have  seen  that,  by  reflex  stimulation,  the 
same  effects  are  observed  internally  as  occur  externally  in  the  skin  area 
treated.  But  when  he  applied  to  the  belly  or  back  of  the  rabbit,  a  wet 
compress  of  the  same  temperature,  it  always  produced  a  prolonged  and 
decided  dilatation  of  the  pial  vessels,  just  opposite  to  the  effect  obtained  in 
the  first  experiment  quoted,  and  which  we  know  was  due  to  reflex  stimula- 
tion. Again,  he  found  that  the  application  of  warm  water  to  the  nerve 
trunk  produced  dilatation  of  the  vessels,  while  warm  water  applied  to  the 
general  skin  surface  by  immersion,  produced  a  narrowing  of  the  pial  vessels. 
Since  the  effects  are  directly  opposite,  both  can  not  be  explained  by  reflex 
action.  Moreover,  Schuller  observed  that  immersion  in  warm  water  pro- 
duced more  decided  narrowing  of  the  vessels  than  a  warm  compress;  and 
immersion  in  cold  water,  a  more  decided  dilatation  of  the  vessels  than  a  cold 
compress.  These  effects  were  in  exact  proportion  to  the  extent  of  surface 
immersed.  When  the  ears  of  the  animal  were  kept  out  of  cold  water,  they 
likewise  filled  with  blood  in  common  with  the  pial  vessels,  but  when  they 
were  also  dipped  into  the  water,  the  vessels  of  the  pia  filled  still  more. 

The  explanation  of  these  contrary  effects  is  quite  obvious  and  will  occur 
to  anyone  acquainted  with  the  principles  of  hydrostatics.  When  the  warm 
compress  was  applied  to  the  animal,  the  cutaneous  vessels  dilated,  thus  in- 
creasing the  flow  of  blood  to,  and  amount  of  blood  in,  the  skin  area  treated. 
This  left  less  blood  to  flow  to  the  brain  and,  in  consequence,  the  blood  vessels 
of  the  pia  were  less  completely  filled.  When  a  greater  surface  was  treated, 
as  by  immersion  in  warm  water,  a  greater  number  of  blood  vessels  were  di- 
lated and  much  less  blood  left  to  flow  to  the  head,  resulting  in  an  increased 
narrowing  of  the  pial  vessels. 

Considering  the  experiment  with  the  cold  compress  and  bath,  we  have  the 
same  underlying  principles.  The  cold  compress  produced  blanching  of  the 
skin  and  a  decreased  amount  of  blood  in  the  periphery,  with  a  resulting  in- 
crease in  the  filling  of  the  blood  vessels  of  the  brain,  because  of  retrostasis. 

Schuller  observed  that  rectal  injections  of  cold  water   always   produced 


BLOOD  PRESSURE  AND  HYDROSTATIC  EFFECTS  45 

some  dilatation  of  the  vessels  of  the  pia.    These  effects  have  been  confirmed 
by  the  experiments  of  Vinaj,  Naumann,  Winternitz  and  others. 

That  these  results  are  hydrostatic,  or  mechanical,  and  not  reflex  is  also  con- 
firmed by  the  changes  in  blood  pressure  observed  at  the  same  time.  In  dila- 
tation of  the  blood  vessels  due  to  vasomotor  action,  there  is  a  fall  of  blood 
pressure.  Quite  the  opposite  occurred  when  the  pial  vessels  dilated  because 
of  a  cold  compress  or  cold  immersion,  i.  e.,  a  decided  rise  in  arterial  pres- 
sure. This  we  know  is  associated  with  vasoconstriction  and  can  not,  there- 
fore, be  due  to  paralysis  of  the  vasomotors.  But  when  we  consider  that  the 
cold  application  produced  blanching  of  the  skin  and  vasoconstriction  over 
quite  a  large  area  and  consequently,  an  increase  in  blood  pressure,  the  whole 
process  is  quite  apparent.  The  retrostasis  and  increase  of  blood  pressure 
causes  the  cerebral  vessels,  which  are  not  under  the  influence  of  the  cold,  to 
fill  in  order  to  accommodate  the  blood. 

The  opposite  group  of  conditions  prevailed  with  the  hot  application:  viz., 
narrowing  of  the  pial  vessels  with  a  fall  in  blood  pressure.  The  same  prin- 


Fig.  13.     Volume  curve  of  right  arm  during  a  sitz  bath  at  110" 
F.,  showing  derivative  effect.     (Winternitz) 

ciples  apply  here  as  above,  opposite  conditions  resulting  from  opposite  causes. 
The  hot  bath  produced  afflux  of  blood  to  the  skin  through  vasodilatation, 
with  a  consequent  decrease  in  blood  pressure,  the  cerebral  vessels  narrowed 
because  of  a  relative  anemia.  If  the  narrowing  of  the  pial  vessels  had  been 
due  to  reflex  action,  there  should  have  been  a  rise  instead  of  a  fall  in  blooc 
pressure. 

Schuller  observed  that  prolonging  the  warm  application  produced  an  increas- 
ing constriction  of  the  cerebral  vessels.     This  may  be  explained  by  the  fact 
that  a  passive  and  extreme  dilatation  of  the  cutaneous  vessels  occurs  wher 
the  heat  is  maintained  for  a  long  time.    This  is  the  effect  of  a  long,  hot  pa( 
which,  in  practice,  we  utilize  where  decided  derivation  is  desi 

The  hydrostatic  effects  of  both  derivation  and  retrostasis  have  been  demon- 
strated by  Winternitz,  '  by  clinical  experiments.     By  means  of  the  plethys- 

1    W.  Winternitz-Physiologische  Grundlagen  der  Hydro-  und  Thermotherapie,  pp.  43,  44. 


46  THE  CIRCULATION- HYDROSTATIC  EFFECTS 

mograph  he  determined  the  volume  curve  of  the  forearm  during  a  hot  sitz 
bath  and  also  during  a  cold  sitz  bath.  The  hydrostatic  results  are 
graphically  shown  in  Figs.  13  and  14-  The  cold  sitz  bath  caused  an  increase 
in  the  volume  of  the  forearm,  due  to  retrostasis,  consequent  on  contraction 
of  the  vessels  under  the  influence  of  the  cold  water.  In  the  case  of  the  hot 
sitz  bath  the  blood  vessels  under  the  influence  of  heat  dilated,  and  being 
more  completely  filled,  caused  a  fall  in  the  volume  of  the  forearm  because 
of  the  derivative  effect. 

Secondary  II ydrostasis.  When  the  cold  applications  were  prolonged,  Schul- 
ler  observed  the  widening  of  the  pial  vessels  give  way  after  a  time  to  narrow- 
ing. In  the  case  of  compresses,  this  change  occurred  after  two  or  three  min- 
utes; with  immersion,  after  jive  to  ten  minutes.  It  is  apparent  to  all,  that 
a  cold  compress,  after  two  or  three  minutes,  becomes  a  heating  compress, 
because  of  the  cutaneous  reaction  and  hence,  a  warm  compress  which  brings 


Fig.  14.       Volume  curve  of  right  arm  during  a  sitz  bath  at  50° 
F.,  shoiving  retrostatic  effect.     (Winternitz) 

about  the  narrowing  of  the  cerebral  vessels.  The  same  is  true  of  the  cold 
bath.  When  reaction  sets  in,  the  skin  becomes  reddened,  its  vessels  are  filled 
with  blood,  and  the  cerebral  vessels  contract.  This  secondary  hydrostatic 
effect  is  of  great  importance  in  the  practical  application  of  derivative  means. 

A  hot  and  cold  percussion  douche  to  the  feet  reduces  cerebral  congestion 
because  of  blood  being  drawn  to  the  extremities  by  the  reaction  in  the 
feet. 

\\  hen  congestion  in  an  organ  has  been  reduced  by  a  hot  pack,  the  deriva- 
tion may  be  secured  (made  more  lasting)  by  completing  the  treatment  with 
a  cold  mitten  friction,  thus  retaining  the  blood  in  the  skin. 

Law  of  Antagonism.  These  hydrostatic  effects  are  well  recognized  by 
physiologists.  There  is  an  antagonism  between  the  vessels  of  the  skin  and 
viscera,  between  the  internal  and  external  vessels,  so  that,  when  the  peri- 
phery is  well  filled,  there  is  a  relative  anemia  of  the  viscera,  and  vice  versa. 


AREAS  FOR  DERIVATION  47 

The  so-called  Dastre-Morat  Law  of  Antagonism  is  thus  stated  by  Sir.  M. 
Foster,  2  "Moreover,  the  vascular  changes  in  the  skin  are  accompanied  by 
cocresponding  vascular  changes  in  the  viscera  (chiefly  abdominal)  of  the  re- 
verse kind.  When  the  vessels  of  the  skin  are  dilated,  those  of  the  viscera 
are  constricted,  and  vice  versa;  so  that  the  blood  ebbs  and  flows,  so  to  speak, 
according  to  circumstances,  from  skin  to  viscera  and  from  viscera  to  skin." 

These  mechanical  effects  are  necessarily  produced  solely  by  vascular  con- 
nection and  not  by  nerve  connection.  Their  extent  depends  upon  nothing  so 
much  as  upon  the  extent  of  surface  involved,  as  was  shown  by  the  experi- 
ments with  the  compresses  and  baths.  This  action  is  not  confined  to  the 
blood  vascular  system,  but  applies  to  the  lymphatic  system  as  well.  A  warm 
application  which  causes  vasodilatation  will,  of  necessity,  draw  blood  from 
all  other  parts  of  the  body;  and  conversely,  a  cold  application,  causing  vaso- 
constriction,  will,  in  the  nature  of  the  case,  drive  the  blood  elsewhere,  prin- 
cipally to  the  interior.  In  either  case,  the  blood  is  driven  into  or  drawn  from 
the  deeper  parts.  In  the  normal  body,  these  hydrostatic  effects  are  more  or 
less  evenly  distributed  over  the  entire  vascular  system,  so  that  the  effect  in 
any  one  part  is  not  so  marked.  For  example,  a  hot  bath  or  pack  in  health 
draws  the  blood  more  or  less  equally  from  all  the  viscera;  but  in  case  of  con- 
gestion of  some  particular  organ,  that  organ  will  be  affected  more  than  others 
by  either  derivation  or  retrostasis.  A  common  example  is  found  in  the  in- 
crease of  pulmonary  congestion,  produced  by  cold  drafts  to  the  shoulders. 
In  a  healthy  person,  this  might  not  result  seriously,  but  in  one  susceptible 
to  colds,  or  with  an  already  existing  congestion,  it  may  cause  an  extreme 
congestion  in  a  very  short  time.  In  the  same  condition,  a  hot  pack  will  draw, 
proportionately,  more  blood  from  the  lungs  than  from  other  parts.  Again, 
a  large  hot  fomentation  to  the  loins,  or  a  hot  pack  would,  under  normal  con- 
ditions, withdraw  from  the  kidneys  only  a  small  amount  of  blood;  but  when 
these  organs  are  congested,  there  is  a  marked  depleting  effect  manifest. 
The  patient  is  bled  into  his  own  limbs  and  skin. 

Not  only  may  areas  quite  distant  from  a  part  be  utilized  for  depleting  that 
part,  but  in  many  cases,  skin  areas  near-by  may  be  used  to  advantage.  That 
this  is  not  a  new  principle  in  therapeutics  will  be  seen  by  referring  to  "leech" 
bleeding.  It  is  directed  that  the  leech  be  applied  to  the  skin  over  the  inflamed 
part.  It  sucks  blood  from  the  superficial  branches  of  the  same  vessels  that 
supply  the  deeper  inflamed  part.  If,  by  hot  applications,  the  arteries  of  the 
superficial  set  of  branches  be  widened  out,  there  will  be  less  blood  to  flow 
into  the  deeper  branches.  Thus,  will  a  fomentation  draw  blood  from  a  part 
near-by  that  received  its  blood  from  the  same  large  artery.  Where  there 
are  large  thick  muscles  under  the  skin  area  treated,  the  total  vascular  capac- 
ity of  both,  when  filled  to  the  limit,  may  produce  a  very  decided  derivation. 

Areas  for  Derivation 

The  various  viscera  are  mechanically  related  to  superficial  and  other  areas 
as  follows.      In  most  cases,  these  areas  are  utilized  for  depleting  (deriva- 
tive) effect,  but  the  opposite  condition  (retrostasis)  may  obtain  where  these 
areas  are  chilled. 
2    Physiology,  p.  287. 


48  THE  CIRCULATION— HYDROSTATIC  EFFECTS 

1.  The  Brain.     Blood  may  be  withdrawn  from  the  brain  by  hot  applica- 
tions to  the  feet,  legs  or  entire  lower  limbs,  also  to  the  spine  or  entire  sur- 
face of  the  trunk.      It  is  not  practical  to  utilize  the  emissary  veins  of  the 
cranial  circulation  for  this  purpose,  since  the  reflex  effect  in  dilating  the  cere- 
bral vessels  would  be  greater  than  the  depleting  effect.     In  cases  of  severe 
sunstroke,  the  vasomotors  are  so  unbalanced  that  even  a  hot  foot  bath  may 
reflexly  produce  cerebral  congestion,  rather  than  depletion,  and  must  there- 
fore be  avoided. 

2.  Spinal  Cord.     Congestion  here,  if  not  too  extreme,  may  be  relieved  by 
large  fomentations  to  the  spine  (entire  width  of  the  back).    This  diverts  the 
blood  from  the  spinal  arteries  into  the  posterior  divisions  of  the  intercostal 
and  lumbar  arteries.     Also  by  hot  applications  to  the  feet,  legs  or  the  skin 
surface  of  the  trunk.    In  cases  of  acute  cerebro-spinal  meningitis,  it  is  best 
to  utilize  the  more  distant  areas. 

3.  Eye.     Applications  may  be  made  to  the  forehead  and  side  of  the  face, 
thus  dilating  some  of  the  terminal  superficial  branches  of  the  carotids,  and 
depleting  the  deeper  branches. 

4.  Middle  Ear  and  Mastoid.     By  applications  to  the  entire  side  of  the  head; 
also  by  very  hot  applications  to  the  legs,  abdomen  and  spine. 

5.  Pharynx  and  Larynx.     By  applications  to  the  neck,  thus  depleting  the 
deeper  organs  and  congesting  the  surface  vessels. 

6.  Lungs  and  Heart.     The  feet  and  lower  limbs,  skin  surface  of  the  trunk 
and  hips,  also  the  hands,  arms  and  shoulders.    Where  the  congestion  is  limited 
to  a  small  area,  as  in  circumscribed  pleurisy,  a  fomentation  may  be  used 
directly  over  that  area.     This  dilates  the  posterior,  lateral  and  anterior  cutan- 
eous branches  of  the  intercostal  arteries,  thereby  withdrawing  blood  from 
the  inflamed  pleura. 

7.  Kidneys.     The  circulation  of  these  organs  is  decreased  by  hot  applica- 
tions to  the  back,  thus  dilating  the  posterior  branches  of  the  lumbar  and 
lower  intercostal  arteries,  and  leaving  less  blood  to  pass  from  the  aorta  to 
the  renal  arteries.    In  extreme  congestion  of  the  kidneys,  it  is  necessary  to 
utilize  much  larger  areas,  as  the  entire  surface  of  the  trunk,  hips  and  legs, 
or  one  of  these  areas  alone. 

8.  Stomach.     By  large  applications  centering  at  the  epigastrium,  but  ex- 
tending over  the  lower  chest  and  sides  of  the  abdomen,  and  well  down  over 
the  umbilical  region;  also  to  the  entire  trunk. 

9.  Liver.     By  applications  to  the  liver,  also  to  the  lower  dorsal  spine  of 
the  right  side,  extending  forward  and  covering  the  epigastric  and  umbilical 
regions.      The  skin  area  of  the  lower  limbs  and  hips  is  as  important,  if  not 
more  so,  than  the  nearer  areas. 

10.  Spleen.     Similar  to  the  liver,  on  the  opposite  side,  also  lower  limbs. 

11.  Pelvic  Organs— Bladder,  uterus,  ovaries,  tubes,  rectum  and  prostate. 
To  deplete  these  organs,  two  principal  areas  are  utilized;  first,  the  entire 
skin  surface  of  the  hips,  pelvis,  etc.,  as  in  a  hot  sitz  bath  or  hot  hip  pack; 
second,  the  lower  limbs,  as  in  a  hot  leg  bath  or  hot  leg  pack.     Both  areas 


VASCULAR  CONNECTION  49 

may  be  utilized  by  the  use  of  the  hot  hip  and  leg  pack  or  hot  half  bath. 

The  student  who  is  familiar  with  the  anatomy  of  the  circulatory  system 
will  be  able  to  figure  out  the  vascular  connections  between  the  organs  men- 
tioned above  and  areas  named  with  each.  In  nearly  every  case,  it  is  quite 
obvious.  These  areas  are  of  importance,  not  alone  in  ordinary  congestion, 
but  of  almost  inestimable  service  in  actual  inflammation  of  these  parts,  as 
shown  later.  (See  Treatment  of  Inflammations.) 


CHAPTER    VIII 

THE  CIRCULATION-BALANCE 
BETWEEN  REFLEX  AND  HYDROSTATIC  EFFECTS 

By  reference  to  the  observations  recorded  under  reflex  and  mechanical 
effects,  it  will  be  seen  that  thermic  applications  to  the  surface  exert  two 
classes  of  effects — a  reflex  and  a  hydrostatic  effect — which  are  directly  oppo- 
site, and  therefore,  conflicting.  Probably,  an  application  produces  more  or 
less  of  both,  though  one  or  the  other  usually  predominates.  Since  they  are 
opposite,  one  will  neutralize  or  overshadow  the  other.  Kellogg  ]  makes  the 
following  statement:  "Doubtless  both  of  these  effects  are  always  produced. 
When  the  application  is  general,  the  mechanical  effect  is  dominant;  when 
the  area  involved  is  limited,  the  reflex  effect  is  prominent.  In  general  appli- 
cations, the  primary  reflex  effect  is  quickly  effaced  by  the  succeeding  mechani- 
cal effect,  due  (in  case  of  cold)  to  the  inrush  of  blood  from  the  periphery. 
This  diversion  of  blood  from  the  surface  vessels  to  the  interior  of  the  body 
is  termed  retrostasis.  Marked  retrostasis  is  produced  only  when  the  cold 
application  is  made  simultaneously  to  a  very  large  cutaneous  area."  These 
are  essentially  the  views  of  Schuller,  who  considered  that,  at  the  beginning 
of  the  application,  the  pial  vessels  were  affected  reflexly,  which  effect  is 
soon  overbalanced  by  the  thermic  effect  upon  the  vessels  of  the  skin. 

"If  the  surface  area  to  which  the  application  is  made  is  small,  the  reflex 
effect  may  be  confined  to  the  internal  area  in  sympathetic  relation  therewith, 
and  will  be  greater  and  more  prolonged  for  the  reason  that  the  reflex  influence 
is  concentrated  upon  a  circumscribed  area;  while  the  mechanical  effect  is 
distributed  over  the  rest  of  the  body  so  that  it  does  not  overshadow  and  wipe 
out  the  reflex  effect  on  the  smaller  area  involved."  Baruch's  comment2 
upon  this  subject  is  as  follows :  '  'Baths  and  other  procedures  without  mechani- 
cal excitation,  when  applied  to  large  portions  of  the  body,  doubtless  have  a 
hydrostatic  effect;  while  douches,  which  impinge  on  limited  portions,  and 
are  combined  with  mechanical  effects  (irritation) ,  act  chiefly  by  reflex  influ- 
ence." 

Is  it  possible  to  determine  which  result  will  be  greater  in  a  given  case,  or 
which  will  be  practically  the  only  effect  from  a  certain  application?  In  reply 
to  this  very  natural  question,  we  may  state  that  there  are  definite  laws 
governing  these  opposing  actions.  By  them,  one  may  so  time  and  regulate 
applications  as  to  secure  a  desired  and  definite  result. 

Laws  of  Balance 

The  following  are  the  laws;  other  things  being  equal,  these  conditions 
obtain: — 

1  Hydrotherapy,  p.  103. 

2  Principles  and  Practice  of  Hydrotherapy,  p.  48. 


LAWS  OF  BALANCE  51 

1.  Size  of  Application  or  Area.    A  small  application  has  a  greater  reflex 
effect.     The  mechanical  effect  predominates  if  the  application  is  large,  and 
the  larger  the  application,  the  greater  the  mechanical  effect. 

2.  Intensity  of  Application.    An  application  of  great  intensity  (very  hot 
or  very  cold,  or  with  percussion)  has  a  greater  reflex  effect.     An  applica- 
tion of  less  intensity  has  a  greater  mechanical  effect. 

3.  Area  Involved  (as  to  location) .     The  chief  result  of  an  application  to 
certain  areas  (example,  the  precordia)  is  a  reflex  effect.    The  principal  re- 
sult of  an  application  to  certain  other  areas  (example,  the  feet  and  legs)  is 
mechanical. 

Duration  of  Application.  The  duration  and  intensity  of  the  effect  de- 
pends upon  the  duration  and  intensity  of  the  application. 

In  the  obtaining  of  either  reflex  or  hydrostatic  effects,  these  factors  are 
not  of  equal  importance  in  governing  the  results.  The  size  of  the  area 
treated  has  a  greater  governing  effect  upon  the  result,  than  the  intensity  of 
the  application.  Stated  in  the  order  of  their  importance  they  are  as  listed 
above.  With  a  few  areas,  however,  the  location  is  of  far  more  importance 
than  either  the  size  or  intensity  of  the  application.  These  areas  are  the  head, 
precordia  and  lower  limbs.  Applications  to  the  two  former,  of  whatever  size 
or  intensity,  always  give  reflex  effects  chiefly,  while  applications  to  the  latter 
nearly  always  give  hydrostatic  effects. 

Examples:  The  prolonged  application  of  an  ice  bag  (small  application  of 
intense  cold)  to  the  precordia  (special  area)  produces  a  (reflex  effect)  pro- 
longed slowing  of  the  rate  of  the  heart  beat,  and  a  decided  increase  in  its 
force  for  the  same  length  of  time.  There  is  very  little  tendency  to  produce 
retrostasis  of  blood  (mechanical) ,  or  engorgement  of  the  heart. 

A  hot  trunk  pack  (large  area)  withdraws  blood  from  the  viscera  (hydro- 
static effect)  rather  than  producing  dilatation  of  their  vessels  (reflex  effect) . 

A  hot  and  cold  douche  to  the  chest  (small  intense  application)  stimulates 
the  heart  and  respiration  (reflex  effect),  rather  than  having  any  decided 
(mechanical)  effect  upon  the  blood  current  of  these  organs. 

Applications  to  the  head  (special  area),  whether  hot  or  cold,  have  a  reflex 
effect  almost  entirely. 

Many  other  examples  might  be  given,  but  the  principles  involved  in  the 
above  are  the  same  as  those  which  govern  other  applications.  It  will  be  seen 
that,  although  reflex  and  mechanical  effects  directly  oppose  each  other,  the 
reflex  overshadows  and  obliterates  the  mechanical  when  certain  areas  are 
involved,  and  when  those  areas  are  small  and  the  application  intense.  The  me- 
chanical effect  wipes  out  the  reflex  effect  when  the  application  is  to  certain 
other  areas,  is  less  intense,  and  especially,  when  these  areas  are  very  large. 

We  have  so  far  discussed  these  two  classes  of  effects  as  to  their  opposing 
results. 

Reflex  and  mechanical  effects  may  be  made  to  assist  each  other  in  secur- 
ing depletion,  when  diverse  applications  are  made  to  different  areas  simul- 
taneously. This  will  be  discussed  under  the  head  of  '  'Derivative  Effects. 


CHAPTER    IX 
THE  CIRCULATION-BLOOD  PRESSURE 


Blood  pressure  is  governed  by  the  following  three  factors: — 

1.  The  heart  beat. 

2.  The  amount  of  blood. 

3.  Vascular  calibre  and  action. 

1.  The  Force  of  the  Heart  Beat,  its  rapidity  and  the  volume  of  its  out- 
put, are  secondarily  influenced  by  the  other  two  factors.    So  closely  related 
are  these  three,  that  practically  one  can  not  be  studied  without  studying  the 
other  two.     Influences  which  bring  about  a  change  in  any  one  of  these  fact- 
ors, produce  through  that   factor  a  change  in  the  remaining  two.     (Figs. 
15  and  16.) 

General  hot  baths,  such  as  hot  air,  electric  light,  Russian,  and  full  hot 
tub  baths,  increase  the  heart  rate  and  decrease  its  force.  This  is  due  to 
reduction  in  the  peripheral  resistance  occasioned  by  the  extensive  vasodila- 
tation  which  is  itself  the  direct  cause  of  the  lowered  blood  pressure.  Gen- 
eral cold  baths  or  even  fair  sized  cold  applications,  increase  blood  pressure 
because  of  the  resulting  vasoconstriction. 

Those  things  which  directly  affect  the  heart  beat,  come  principally 
through  reflex  stimulation.  All  sorts  of  cold  applications  to  the  precordia 
increase  the  force  of  the  muscular  contractions  and  so  raise  blood  pressure. 
After  a  brief  rise,  hot  "applications  to  the  precordia  decrease  blood  pres- 
sure. Short  cold  applications  to  the  precordia  increase  the  heart  rate, 
while  long  cold  applications  decrease  the  heart  rate.  In  the  normal  person, 
both  results  are  associated  with  a  rise  in  blood  pressure.  Rapidly  alternat- 
ing hot  and  cold  applications  to  the  precordia  have  much  the  same  effect  as 
short  cold  applications,  except  that  the  stimulation,  being  greater,  causes  a 
greater  rise  in  blood  pressure.  This  rise  is  less  permanent  than  that  ac- 
companying prolonged  cold  applications  to  the  precordia.  These  points 
have  been  thoroughly  discussed  elsewhere. 

2.  The  Amount  of  the  Circulating  Fluid.    An  increase  in  the  quantity  of 
blood  in  the  vascular  system,  other  things  being  equal,  increases  blood  pres- 
sure.    In  order  to  intelligently  apply  those  therapeutic  measures  which  are 
designed  to  maintain  blood  pressure  through  changes  in  the  amount  of  the 
circulating   fluids,  it  is  necessary  to   obtain  an  understanding  of  the  laws 
governing  the  intake  and  output  of  body  fluids,  and  also  the  absorption  of 
extravascular  tissue  fluids.     Modern  knowledge  of  the  fluids  of   the   body 
has  recently  been  summarized  by  E.    H.  Starling.  l     From  this  source  we 
have  drawn  much  of  the  following  information. 

The  absorptive  membranes  of  the  body  possess  a  discriminating  or  irrecip- 
rocal permeability  to  fluids,  i.  e.,  fluids  containing  certain  saline  substances 

1     Herter  Lectures,  New  York,  1908. 


i 


54  THE  CIRCULATION-BLOOD  PRESSURE 

are  readily  and  rapidly  absorbed,  while  fluids  containing  other  salts  are 
either  not  absorbed,  or,  only  after  long  contact. 

"If  the  solutions  contain  sulphates  or  tartrates,  i.  e.,  salts  to  whose 
anions  the  gut  wall  is  relatively  impermeable,  the  course  of  events  is  very 
much  the  same  as  that  which  would  occur  if  these  solutions  were  separated 
from  blood-plasma  by  a  dead  wall  of  parchment  paper.  If  they  are  hyper- 
tonic,  they  increase  in  amount  by  the  attraction  of  water  from  the  circu- 
lating fluids,  until  their  molecular  concentration  is  equal  to  that  of  blood- 
plasma."2  By  long  contact  they  are  finally  absorbed.  "Very  different  is 
the  fate  of  solutions  of  substances  such  as  sodium  chloride.  These  are 
rapidly  absorbed  even  when  they  are  slightly  hypertonic.  If  the  solutions 
are  strong,  i.  e.,  two  or  three  per  cent  NaCl,  they  at  first  increase  in  bulk 
by  the  diffusion  of  water  into  them.  From  the  moment  of  their  introduction, 
however,  salt  is  passing  from  them  into  the  blood,  circulating  through  the 
intestinal  wall,  and  as  soon  as  their  total  osmotic  pressure  is  reduced  to  a 
point  a  little  above  that  of  the  blood-plasma,  both  water  and  salt  begin  to 
be  absorbed." 3 

This  selective  action  is  found  to  depend  upon  the  vitality  of  the  cells  com- 
posing the  membrane,  since  it  ceases  when  the  cells  have  been  damaged  by 
certain  chemicals.  The  fate  of  fluid  introduced  into  the  gut  then  seems  to 
depend  entirely  upon  its  concentration.  The  epithelial  cells  composing  the 
mucous  membrane  of  the  intestine  possess  the  power  of  pumping  water  and 
salts  from  one  side  of  the  cell  to  the  other.  "This  conclusion  is  confirmed 
by  certain  experiments  of  Reid  and  Cohnheim,  in  which  two  identical  solu- 
tions of  sodium  chloride  were  separated  from  one  another  by  a  membrane 
consisting  of  the  whole  living  intestinal  wall.  In  these  experiments,  it  was 
found  that  there  was  active  transference  from  the  inner  to  the  outer  side  of 
the  membrane."  4  The  same  was  found  to  hold  true  with  the  skin.  When 
brought  in  contact  with  deleterious  substances,  the  cells  of  the  skin  behaved 
like  ordinary  dead  membrane,  the  irreciprocal  permeability  and  the  active 
transference  of  fluid  totally  disappearing. 

Saline  solutions,  somewhat  less  in  concentration  than  blood  serum,  are  very 
rapidly  absorbed  from  the  intestine,  somewhat  more  so  than  even  isotonic 
solutions.  The  rapid  absorption  of  hypotonic  or  isotonic  solutions  introduced 
into  the  bowel,  is  then  shown  to  be  due  to  the  specific  activity  of  the  epi- 
thelial cells,  aided  by  the  greater  osmotic  pressure  of  blood  serum  in  the 
case  of  hypotonic  solutions.  The  ready  and  constant  absorption  of  fluid 
which  occurs  with  the  Murphy  method  of  enteroclysis,  is  a  most  effectual 
means  of  maintaining  blood  pressure  at  an  even  point.  In  case  of  much  loss 
of  fluid  or  lowering  of  blood  pressure,  after  a  fairly  normal  amount  of  fluid 
and  degree  of  blood  pressure  has  been  secured  by  the  absorption  of  the  saline 
fluid,  the  salt  solution,  if  injected  slowly,  is  eliminated  by  the  kidneys  at  the 
same  rate  at  which  it  is  absorbed.  5 

The  laws  of  osmosis  when  working  in  connection  with  the  intestinal  wall 
above  referred  to,  account  for  the  hydrogogue  action  of  hypertonic  solutions 

2  Starling— The  Fluids  of  the  Body,  p.  53. 

3  Ibid.,  p.  53. 

4  Ibid.,  p.  57. 

5  Ibid.,  p.  139. 


ABSORPTION  OF  TISSUE  FLUIDS 


55 


of  such  substances  as  Epsom  salts,  Rochelle  salts  and  honey,  when  injected 
into  the  bowel.  Strong  solutions  of  these  substances  cause  an  exosmosis, 
i.  e.,  when  they  remain  a  comparatively  short  time  water  is  drawn  from 
the  circulating  fluid  and  increases  the  bulk  of  the  injected  fluid.  This  "wash- 
ing" through  the  mucous  membrane  clears  it  of  mucus,  helps  dislodge  mucus 

casts,  etc.  These  obser- 
vations furnish  a  ration- 
al basis  for  the  use  of 
the  hypertonic  saline  en- 
ema, and  the  honey  or 
molasses  enema,  in  mu- 
cous colitis. 

In  regard  to  the  ab- 
sorption of  interstitial 
fluids,  and  of  fluid  intro- 
duced by  hypodermocly- 
sis,  Starling  concludes 
that  this  occurs  mostly 
by  the  blood  rather  than 
the  lymphatics,  as  has 
long  been  supposed.  In- 
digo, carmine  or  methy- 
lene  blue  injected  into 
the  pleural  or  peritoneal 
cavities,  may  appear  in 
the  urine  within  six 
•minutes  after  the  mo- 
ment of  injection  at  a 
time  when  the  lymph  in 
the  thoracic  duct  is  free 
from  color.  Strychnin 
or  other  drug  injected 
under  the  skin  of  a  limb 

Fig.  16.  Cardiometer  tracing  from  dog's  exerts  its  poisonous  ef- 
heart  showing  effect  of  increasing  the  volume  of  fects  on  the  nervous 
circulating  fluid  on  the  total  output  and  volume  system  long  before  the 
of  the  heart.  Between  the  parts  A  and  B,  30 
c.  c.  of  warm  physiologic  salt  solution  were  in- 
jected intravenously,  and  between  B  and  C, 
20  c.  c.  more.  Both  the  systolic  and  diastolic 
volume  are  increased,  i.  e.,  the  heart  is  more 
distended  during  diastole,  and  does  not  contract 
to  its  normal  size  in  systole.  The  result  is  a 
very  largely  increased  output.  (Roy) 


drug  itself  appears  in 
the  lymph  flowing  from 
the  limb.  It  has  been 
shown  that  blood  re- 
turning from  an  edema- 
tous  limb  is  more  dilute 
than  blood  returning 
from  a  normal  limb. 


The  experiment  con- 
ducted by  Starling6  is  as  follows:  By  means  of  cannulas  inserted  into  the 
femoral  artery  and  vein,  defibrinated  blood  of  the  same  osmotic  pressure  as 
normal  blood  serum,  was  caused  to  pass  through  the  arteries,  capillaries 


6    Ibid.,  p.  95. 


56  THE  CIRCULATION— BLOOD  PRESSURE 

and  veins  of  the  normal  leg  of  a  dog.  The  same  was  done  with  the  opposite 
leg  made  edematous  by  the  injection  of  a  one  per  cent  solution  of  NaCl. 
Blood  which  had  been  led  through  the  normal  leg  twelve  to  twenty-five  times 
was  unaltered  or  suffered  trifling  change,  while  that  led  the  same  number 
of  times  through  the  edematous  leg  had,  in  all  cases,  absorbed  fluid.  "From 
these  experiments,  we  may  affirm  with  certainty  that  isotonic  salt  solutions 
can  be  taken  up  directly  by  the  blood  circulating  in  the  blood  vessels."7 
Hypodermoclysis  is  the  most  rapid  method  (aside  from  direct  vein  injection) 
of  introducing  fluid  into  the  circulation.  Increase  in  the  amount  of  fluid  in 
the  vascular  system  results  in  heightened  venous  pressure,  which,  in  turn, 
produces  an  increase  in  diastolic  filling,  systolic  output  and  arterial  pressure 
and  greatly  hastens  the  velocity  of  the  circulation.  (Fig.  16)  "Blood  with 
its  lower  velocity  passes  readily  through  the  dilated  arterioles  and  capillaries, 
so  that  the  velocity  of  the  blood-flow  may  be  easily  increased  from  six  to 
ten  times."  8  Injecting  salt  solution  equivalent  to  50  per  cent  of  the  total 
blood,  has  been  found  to  augment  the  velocity  of  the  blood  six  to  eight  times 
the  normal  rate.  9 

The  rise  in  blood  pressure  occasioned  by  the  absorption  of  fluid  introduced 
by  either  hypodermoclysis  or  proctoclysis,  is  of  special  advantage  in  various 
conditions  where  the  blood  pressure  has  fallen  very  low,  such  as  in  collapse 
(after  hemorrhage),  in  peritonitis,  etc.  The  Murphy  method  of  proctoclysis 
is  especially  recommended  in  the  treatment  of  peritonitis  after  the  institu- 
tion of  surgical  drainage.  It  is  designed  to  flush  the  drained  surfaces,  and 
so  aid  in  getting  rid  of  septic  material  and  infection.  We  believe  its  bene- 
ficial action  is,  however,  due  as  much  to  the  maintenance  of  blood  pressure, 
as  to  the  flushing  of  the  absorbents  and  drained  surfaces. 

Given  in  the  order  in  which  they  most  rapidly  increase  the  volume  of  the 
blood,  the  methods  of  introducing  fluid  into  the  circulatory  system  may  be 
listed  as  follows:— 

a.  Hypodermoclysis. 

b.  Proctoclysis. 

c.  Water  drinking. 

3.  Vascular  Calibre  and  Action.  We  have  seen  that  a  hot  application 
dilates  the  blood  vessels,  producing  an  afflux  of  blood  to  the  skin  and  super- 
ficial parts,  increasing  with  the  prolongation  of  the  application.  It  has  also 
been  shown  that  the  reaction  to  a  cold  application  produces  an  afflux  of  blood 
to  the  skin.  In  both  cases,  there  is  a  hyperemia  established,  but  the  two 
are  of  an  entirely  different  nature.  With  the  hot  application,  there  is  a  fall 
of  blood  pressure  because  of  a  loss  of  tone  in  the  vessels  (passive  dilatation) 
and  a  preponderance  of  venous  blood  in  the  part.  While  the  dilatation  which 
comes  with  the  reaction  to  a  cold  application  is  accompanied  by  an  increase 
in  blood  pressure,  the  tone  of  the  vessels  is  preserved,  and  there  is  a  pre- 
ponderance of  arterial  blood  in  the  part.  These  conditions  are  respectively 
known  as  venous  or  passive  hyperemia  and  arterial  or  active  hyperemia.  It 
is  important  to  distinguish  the  physiologic  difference  between  the  hyperemia 
of  cold  and  that  of  hot  applications.  In  the  case  of  the  hot  application, 

7  Ibid.,  p.  97. 

8  Ibid.,  p.  138. 

9  Starling— Physiology,  p.  284. 


VASCULAR  CALIBRE  AND  ACTION  57 

there  is  a  slowing  of  the  circulation,  a  stasis  of  blood,  which  necessarily 
results  in  an  increase  of  the  venous  over  the  arterial  blood  in  the  part.  With 
the  cold  application,  after  the  initial  vasoconstriction  and  anemia  have  given 
way,  the  return  to  a  normal  condition  (reaction)  is  accompanied  by  an  in- 
crease of  from  three  to  five  times  in  the  rapidity  of  the  circulation.  10  The 
blood  flows  rapidly  through  the  part  and  consequently,  arterial  blood  predomi- 
nates. This  is  no  small  factor  in  nutrition  and  healing.  In  fact,  it  is  upon 
the  blood  that  both  depend;  they  are  carried  on  and  hastened  in  proportion 
to  the  amount  of  arterial  blood  supplied  to  the  tissues. 

Bier,  in  his  work  on  the  treatment  of  disease  by  hyperemia,  claims  for 
the  tissues  a  selective  action,  i.  e.,  that  they  have  the  power  to  select  arterial 
in  preference  to  venous  blood.  It  would  appear  irrational  to  suppose  any- 
thing else.  The  essential  feature  is  not  in  the  selective  action,  but  in  the 
supplying  of  sufficient  arterial  blood  so  that  the  tissues  may  manifest  their 
selective  action.  The  cold  has  also  a  direct  action  on  the  hemoglobin  in  pro- 
ducing a  higher  degree  of  oxygenation,  i.  e.,  a  greater  oxygen  carrying 
capacity.11 

The  pumping  action  of  the  arteries  under  the  influence  of  reaction  to  cold, 
drives  the  blood  into  the  veins.  Because  of  this,  the  right  side  of  the  heart 
is  more  completely  filled,  and  there  results  a  fuller  output  to  the  lungs  and 
from  the  left  side  of  the  heart.  These  forces  tend  to  produce  a  slower  and 
more  vigorous  systole,  and  so  the  entire  cycle  of  changes  brings  about  a 
heightened  blood  pressure.  These  facts  demonstrate  the  great  value  of  the 
cold  mitten  friction  in  surgical  shock. 

Muller's  Laws.  Very  briefly  stated,  the  following  are  the  chief  effects  of 
external  applications  upon  the  blood  pressure: — 

1.  Effects  of  Cold.     Baths  and  thermic  applications,  not  accompanied  by 
mechanical  irritation,  if  given  below  the  temperature  of  the  skin,  produce 
increased  blood  pressure  with  slowed  pulse  rate. 

2.  Effects  of  Heat.     Thermic   applications   above   the  skin  temperature, 
after  a  brief  rise,  produce  a  fall  in  blood  pressure  which  later  rises.      Hot 
baths  above  104°  F.  persistently  increase  blood  pressure  and  the  pulse  rate. 

3.  Effects  of  Neutral  Temperatures.     Neutral  baths  equalize  or  regulate 
blood  pressure. 

4.  Effects  of  Mechanical  Stimuli.     With  douches  and  other  procedures, 
where  the  mechanical  irritation  is  the  predominant  factor,  there  is  a  rise  of 
blood  pressure  less  enduring  than  with  cold  applications.      "Every  hot  or 
cold  douche  calls  forth  an  increase  of  blood  pressure,  paradoxical  as  it  may 
seem."  12 

10  Baruch— Principles  and  Practice  of  Hydrotherapy,  p.  55. 

11  This  active  arterial  hyperemia  is  undoubtedly  due  to  the  action  of  cold  on  the  tissues,  hemo- 
globin and  the  blood  vessels  themselves.   This  has  been  confirmed  by  Ritter,  who  performed  two 
very  interesting  experiments  to  demonstrate  this  fact.     By  means  of  an  ethyl  chloride  spray,  he 
froze  a  spot  on  the  arm.     After  it  had  thawed,  it  became  bright  red  from  the  reaction.   He  then 
applied  an  elastic  bandage  to  the  arm  above  the  spot.    The  whole  arm  became  dark  blue,  while 
the  previously  frozen  spot  remained  bright  red.     He  reversed  the  experiment  by  first  producing 
cyanosis  and  venous  stasis,  and  then  freezing  a  spot  on  the  arm  below  the  bandage.      After 
thawing,  it  became  bright  red,  while  the  rest  of  the  arm  remained  blue. 

12  Hinsdale— Hydrotherapy,  p.  48. 


58  THE  CIRCULATION— BLOOD  PRESSURE 

The  experiments  of  Schuller  already  quoted,  sustain  these  observations. 
Many  other  experiments  along  this  line  might  be  quoted.  Kellogg 13  records 
an  experiment  in  which  the  drinking  of  a  large  quantity  of  cold  fluid  (50°  F.) 
raised  the  arterial  tension  as  taken  by  Gartner's  tonometer  from  13.5  cm. 
to  14.5  cm.  The  first  observation  was  made  immediately  before,  and  the 
second  immediately  after  the  drinking  of  the  cold  water.  In  another  clinical 
experiment  H  an  initial  arterial  tension  of  9  cm.  was,  by  an  electric  light 
bath,  raised  to  10  cm.  within  one  minute.  At  the  end  of  five  minutes,  the 
tension  had  fallen  to  8  cm.  and  in  twenty  minutes,  to  7  cm.  In  another 
case, 15  fifteen  minutes  in  a  full  bath  at  102°  F.  reduced  the  blood  tension 
from  9  cm.  to  6  cm.,  as  shown  by  Gartner's  tonometer. 

13  Rational  Hydrotherapy,  p.  1116. 

14  Ibid.,  p.  1122. 

15  Ibid.,  p.  1128. 


CHAPTER   X 

THE  CIRCULATION-CHANGES  IN  THE  COMPOSITION 
OF  THE  BLOOD 

Corpuscular  Elements 

Such  a  large  volume  of  experimental  work  has  been  reported  along  this 
line,  that  we  can  not  do  more  than  tabulate  the  principal  results  observed. 
The  investigations  of  Prof.  Winternitz,  and  those  of  Strasser,  undertaken  at 
his  request  and  reported  in  1893,  are  considered  the  basis  of  our  knowledge 
of  these  changes.  The  results  obtained  were  so  uniform  as  to  leave  little 
doubt  of  their  reliability.  After  all  sorts  of  cold  procedures,  involving  the 
general  skin  surface  and  associated  with  mechanical  procedures,  after  hot 
baths  or  douches  when  followed  by  cold  applications,  the  blood  counts  revealed 
an  increase  in  both  the  red  cells  and  white  cells,  and  a  marked  change  in  their 
ratio.  The  greatest  increase  in  red  cells  amounted  to  1,860,000  per  cubic 
millimeter;  in  white  cells,  from  200  to  300  per  cent  and  in  hemoglobin,  14 
per  cent. 

On  the  first  and  third  bath  days  of  Strassers  experiments,  referred  to  in 
Chapter  XI,  blood  counts  were  taken  after  the  cold  douche  and  after  the 
graduated  half  bath.  The  counts  were  as  follows: — 

Effects  of  Cold  Douche  Before  After 

Red  Cells 4,570,000 5,200,000 

White  Cells 4,600 6,400 

Hemoglobin  (Fleischl) 85$> 95# 

Effects  of  Graduated  Half  Bath  Before  After 

Red  Cells 4,880,000 5,420,000 

White  Cells 5,400 8,400 

Hemoglobin ...85^..  ~  950 

These  changes  were  maintained  for  from  one-half  hour  or  one  hour  up  to 
two  hours  or  longer  after  applications,  gradually  returning  to  normal.  The 
increase  in  the  white  cells  was  maintained  longer  than  the  increase  in  reds. 
These  observations  have  been  confirmed  by  Thayer,  Baruch  and  Kellogg,  in 
this  country. 

Where  do  these  cells  come  from?  Repeated  cold  applications  stimulate 
hematogenesis,  as  they  stimulate  all  other  functions.  But,  of  course,  so 
great  an  increase  as  30  or  35  per  cent  in  the  total  number  of  reds  and  200 


60  BLOOD  COMPOSITION 

per  cent  in  the  total  number  of  whites  could  not  result  from  a  single  appli- 
cation. This  increase  in  the  corpuscular  elements  in  the  peripheral  circula- 
tion must  be  at  the  expense  of  the  number  elsewhere.  Winternitz  claims 
that  this  increase  of  cells  in  the  peripheral  circulation  is  due  to  the  driving 
of  large  numbers  of  cells  from  the  viscera,  where  stasis  has  taken  place. 
Breitenstein  l  has  confirmed  this  view  by  experiments  upon  rabbits.  These 
animals  were  overheated  in  a  hot  box,  before  and  after  which  the  red  cells 
in  the  peripheral  circulation  (ear)  and  viscera  (liver)  were  estimated.  Before 
the  heating  process,  the  cells  in  the  ear  and  liver  were  equal  in  number.' 
After  it,  there  was  an  enormous  increase  in  the  red  blood  cells  in  the  liver. 
Tschlenoff  observed  a  decrease  of  50  per  cent  in  the  white  cells  in  rabbits 
subjected  to  a  temperature  of  42°  C.  for  five  or  six  hours.  These  experi- 
ments also  confirm  the  observation  of  Winternitz  and  others,  that  hot  appli- 
cations decrease  the  blood  count  and  the  hemoglobin  per  cent,  the  white  cells 
suffering  a  greater  diminution  than  the  reds. 

Mechanism  of  Distribution.  The  change  in  the  distribution  of  the  red  and 
white  cells  produced  by  cold  applications  is,  to  a  great  degree,  due  to  the 
stimulation  of  the  peripheral  circulation.  This  is  not,  however,  the  only 
factor  in  bringing  about  an  increase  of  cells  in  the  surface  circulation.  The 
viscera  and  their  blood  vessels  are  subject  to  the  reflex  stimulation  produced 
by  cold  applications.  The  contraction  of  the  viscera  and  the  visceral  blood 
vessels,  caused  by  cold  applications,  drives  their  contained  corpuscles  to  other 
parts,  and  these  are  taken  up  by  the  increased  activity  of  the  peripheral 
circulation  and  so  redistributed.  In  both  the  liver  and  spleen  the  blood  cells 
are  especially  prone  to  accumulation  and  stasis.  The  blood  vessels  of  both 
may  be  rendered  very  active;  but  owing  to  the  additional  muscle  fibers  in 
the  capsule  and  trabeculas  of  the  spleen,  this  organ  exerts  a  greater  effect 
upon  the  blood  current  than  that  of  any  other  viscus  except  the  heart. 

"The  most  definite  facts  known  about  the  spleen  are  in  connection  with 
its  movements.  It  has  been  shown  that  there  is  a  slow  expansion  and  con- 
traction of  the  organ  synchronous  with  the  digestion  periods.  After  a  meal 
the  spleen  begins  to  increase  in  size,  reaching  a  maximum  at  about  the  fifth 
hour,  and  then  slowly  returns  to  its  previous  size.  This  movement,  the 
meaning  of  which  is  not  known,  is  probably  due  to  a  slow  vasodilatation, 
together,  perhaps,  with  a  relaxation  of  the  tonic  contraction  of  the  muscula- 
ture of  the  trabeculae.  In  addition  to  this  slow  movement,  Roy  has  shown 
that  there  is  a  rythmical  contraction  and  relaxation  of  the  organ,  occurring 
in  cats  and  dogs  at  intervals  of  about  one  minute. 

"Roy  supposes  that  these  contractions  are  affected  throught  the  intrinsic 
musculature  of  the  organ, — that  is,  the  plain  muscle  tissue  present  in  the 
capsule  and  trabeculae, — and  he  believes  that  the  contractions  serve  to  keep 
up  a  circulation  through  the  spleen  and  to  make  its  vascular  supply  more  or 
less  independent  of  variations  in  general  arterial  pressure.  The  fact  that 
there  is  a  special  local  arrangement  for  maintaining  its  circulation,  makes 
the  spleen  unique  among  the  organs  of  the  body,  but  no  light  is  thrown 
upon  the  nature  of  the  function  fulfilled.  The  spleen  is  supplied  richly  with 
motor  nerve  fibres  which  when  stimulated  either  directly  or  reflexly  cause 
the  organ  to  diminish  in  volume.  According  to  Schaefer,  these  fibres  are 

1    Archiv.  fur  Exper.  Path,  und  Pharm.,  Bd.  32,  18%. 


MOVEMENTS  OF  THE  SPLEEN  61 

contained  in  the  splanchnic  nerves,  which  carry  also  inhibitory  fibres  whose 
stimulation  causes  a  dilatation  of  the  spleen."2 

The  blood  of  the  splenic  veins  contains  a  greater  number  of  white  cells 
than  the  arterial  blood  supplied  to  the  organ.  Miescher 3  experimenting  with 
Rhine  salmon  found  four  times  as  many  leucocytes  in  the  splenic  blood  as  in 
the  cardiac  blood.  This  increase  in  the  cellular  elements  increases  the 
viscosity,  and  consequently  tends  to  diminish  the  rate  of  blood  flow.  The 
gathering  up  of  these  cells,  together  with  the  closeness  of  the  splenic  mesh- 
work  in  which,  the  blood  circulates,  makes  necessary  some  mechanism  for 
additional  propulsive  force. 

"It  is  evident  that  the  blood  must  meet  with  considerable  resistance  in 
passing  through  the  close  meshwork  of  the  splenic  pulp.  To  ensure  a  con- 
stant circulation  through  the  gland,  we  find  that  the  muscular  tissue  of  the 


CAROTID 


Doc.  8,  5  KILO  ALL  CONNECTIONS  WITH  SPLC.CN 

SEVERED   EXCEPT  ONE  ARTERY  &   VEIN   * 
0  PRESSURE 


Fig.  17.  Plethysmographic  tracing  of  spleen  (upper  curve)  from 
dog,  showing  the  spontaneous  rhythmical  contractions  of  this  organ, 
(after  Howell) 

capsule  and  trabeculae  has  the  property  of  rhythmic  contraction.  If  the 
spleen  be  inclosed  in  a  plethysmograph,  or  splenic  oncometer,  and  its  volume 
be  recorded  by  connecting  this  with  the  oncograph,  it  will  be  seen  that  it  is 
subject  to  a  series  of  large,  slow  variations,  each  contraction  and  expansion 
lasting  about  a  minute,  and  recurring  with  great  regularity.  (Fig.  17. )  Super- 
posed on  these  large  waves  are  seen  the  smaller  undulations  due  to  the  res- 
piratory variations  of  the  blood  pressure,  and  on  these  again  the  little  ex- 
cursions corresponding  to  each  heart-beat.  The  contractile  power  of  the 
spleen  is  under  the  control  of  the  nervous  system,  and  a  rapid  contraction 
may  be  induced  by  stimulation  of  the  splanchnic  nerves."4 

The  use  of  cold  applications,  especially  when  accompanied  by  mechanical 
stimulation  such  as  the  cold  mitten  friction  to  the  abdomen,  and  the  cold 
splenic  douche,  have  a  decidedly  stimulant  effect  upon  the  movements  of 
the  spleen.  The  same  is  true  of  the  revulsive  compress  and  the  alternate 
hot  and  cold  douche  to  the  splenic  region  and  abdomen.  Such  stimulation 

2  Howell— Physiology,  1909,  p.  800. 

3  Bunge-Physiologic  and  Pathologic  Chemistry,  Second  English  Edition,  p.  229. 

4  Starling— Elements  of  Human  Physiology,  1907.  p.  514. 


62  BLOOD  COMPOSITION 

increases  the  extent  and  force  and  greatly  enhances  the  efficiency  of  the 
splenic  contractions  thereby  proving  a  powerful  means  of  accomplishing  the 
even  distribution  of  the  blood  cells,  especially  the  leucocytes. 

Not  the  least  interesting  of  the  observations  made  by  Winternitz  is  that 
relating  to  the  local  increase  in  the  blood  count  taken  from  circumscribed 
areas,  treated  by  douches,  partial  baths,  etc.,  while  the  count  taken  from  a 
distant  part  showed  a  decrease  in  both  the  red  and  white  cells.  This  experi- 
ment furnishes  a  rational  basis  for  the  local  use  of  thermic  applications  to 
an  infected  part. 

Massage  as  well  as  hydrotherapy  produces  an  increase  in  the  number  of 
the  blood  corpuscles  as  shown  by  counts  taken  before  and  after  treatment. 
The  effect  is  at  first  temporary,  but  lasts  longer  and  longer  as  the  massage 
is  continued  from  day  to  day  or  week  to  week,  until  finally  the  improvement 
becomes  permanent.  Astonishingly  good  results  have  been  reported  by  Mit- 
chell5 in  cases  of  anemia. 

Viscosity  and  Reaction 

Grawitz  and  also  Burton-Opitz  6  have  shown  that  cold  applications  increase 
the  viscosity  and  specific  gravity  of  the  blood,  while  warm  applications 
decrease  both.  This  thinning  of  the  blood  continued  even  after  prolonged 
heating  with  free  perspiration.  This  result  Burton-Opitz  attributed  to  the 
blood  becoming  relatively  richer  in  serum  at  the  expense  of  the  tissues. 
These  facts  have  been  confirmed  by  Loewy  and  agree  with  those  of  Winter- 
nitz and  Knoepfelmacher. 

In  general,  it  may  be  said  that  conditions  that  produce  vasoconstriction 
increase  the  number  of  corpuscles  in  the  vessels  constricted,  together  with 
an  increase  in  the  specific  gravity  and  viscosity  of  the  blood.  Conversely, 
conditions  that  relax  the  blood  vessels,  decrease  the  corpuscular  elements  in 
the  dilated  vessels,  together  with  a  thinning  of  the  blood. 

Strasser  7  has  shown  that  cold  applications  increase  the  alkalinity  of  the 
blood  through  a  decrease  in  the  quantity  of  acid  phosphate,  even  to  the 
extent  of  50  per  cent.  Also,  that  hot  applications  decrease  its  alkalinity  by 
increasing  the  amount  of  acid  phosphate,  in  one  case  more  than  doubling  it. 

Practical  Application 

Some  of  the  most  beneficial  results  of  hydriatic  measures  are  due  to  the 
facts  recorded  above.  In  the  majority  of  diseases,  there  is  a  reduction  in 
the  alkalinity  of  the  blood.  This  is  particularly  true  of  fevers  and  infectious 
diseases.  An  agent  which  will  tend  to  restore  the  blood  to  its  normal  alka- 
linity will  hasten  all  the  processes  of  repair. 

The  role  of  the  leucocyte  (phagocytosis)  in  combating  infection  is  now  an 
established  fact.  The  admirable  researches  of  Metchnikoff  along  this  line 
leave  no  doubt  that  the  white  cell  itself  is  the  prime  factor  (and  that  not 
excepting  opsonin)  in  phagocytosis,  the  production  and  maintenance  of 
immunity  and  the  body's  general  resistance  to  bacterial  invasion.  He  has 

5    Journal  American  Medical  Association,  October  9,  1909,  p.  1183. 


5  Journal  American  Medical  Association,  October  9, 

6  Journal  of  Experimental  Medicine,  January,  1906. 

7  Deutsche  Medizinal-Zeitung,  June  15,  18%. 


PRACTICAL  APPLICATION  63 

shown  8  what  signal  disaster  to  the  production  and  even  the  continuance  of 
immunity,  results  from  the  administration  of  alcohol,  quinin,  opium  and 
other  medicinal  substances;  this  disaster  being  manifest  by  a  diminution  in 
the  number  and  especially  in  the  activity  of  the  white  blood  cells.  We  have 
every  reason  to  believe  that  cold  hydriatic  applications  not  only  increase  the 
number  of  leucocytes  in  the  peripheral  circulation,  but  also  energize  their 
action— amoeboid  movements,  phagoctosis  and  the  production  of  antibodies. 
This  we  might  safely  infer  from  the  results  obtained  by  cold  applications  in 
increasing  muscular  capacity,  glandular  activity,  etc.  All  protoplasm, 
whether  of  muscle  cells,  glandular  epithelium,  or  leucocyte,  responds  alike 
to  the  tonic  influence  of  short  vigorous  cold  applications.  The  writer  has 
repeatedly  seen  infections  of  the  hand  and  arm  clear  up  in  four  to  six  days, 
or  even  less  time,  when  treated  by  alternating  extreme  hot  and  cold  immer- 
sion, while  other  cases  not  so  treated  have  required  a  month  to  accomplish 
the  same  results. 

Since  the  cells  are -the  source  of  opsonin,  agglutinins,  lysins  and  other 
antibodies  concerned  in  immunity,  it  is  but  reasonable  to  expect  an  increase 
in  these  as  a  result  of  the  cellular  stimulation  produced  by  cold  or  alternate 
hot  and  cold  applications.  This  has  been  partially  demonstrated  by  Graziani,  9 
who  found  that  of  rabbits  injected  with  the  filtrates  of  typhoid  cultures,  and 
kept  at  different  temperatures  (plus  38,  37,  2  and  minus  4°  C.),  those  kept 
at  low  temperatures  developed  more  agglutinin  than  those  kept  at  higher 
temperatures.  He  also  experimented  with  rabbits  kept  at  32°  C.,  bathing 
half  of  the  number  morning  and  evening,  in  water  at  20°  C.  for  thirty  min- 
utes. The  animals  treated  by  bathing  produced  more  agglutinin  than  the 
others. 

These  facts  demonstrate  the  truth  of  the  Scripture  statement  that  the 
blood  is  the  life.  The  statement  has  not  only  its  spiritual  application,  but  is 
also  founded  upon  demonstrated  physical  facts. 

8  The  New  Hygiene. 

9  Centralblatt  fur  Bakteriologie,  1907,  I.  XLII,  633. 


CHAPTER   XI 


NITROGENOUS  METABOLISM  AND  EXCRETION 


Tissue  changes  lie  at  the  foundation  of  all  functional  activity.  There  can 
be  no  vital  action  without  corresponding  qualitative  and  quantitative  changes 
in  tissue  composition.  It  must  therefore  follow  that  agents,  such  as  thermic 
impressions,  in  awakening  functional  activity,  should  at  the  same  time  pro- 
duce profound  alterations  in  absorption,  metabolism  and  excretion.  Without 
giving  undue  prominence  to  this  phase  of  the  subject,  it  would  be  impossible 
to  discuss  it  here  in  anything  like  a  complete  manner.  Those  desiring  to 
become  more  thoroughly  conversant  with  the  behavior  of  metabolism  under 
hydriatic  therapy  should  study  the  original  reports  of  such  research.  Along 
this  line  none  are  more  instructive  than  those  of  Dr.  Alois  Strasser,  assist- 
ant to  P.  of.  W.  Winternitz  in  the  Allegemeine  Poliklinik  of  Vienna,  from 
whose  monograph  entitled,  "The  Behavior  of  Metabolism  under  Hydriatic 
Therapy,"  '  is  drawn  much  of  the  data  for  the  following  discussion. 

Cellular  activity  is  affected  reflexly  in  the  same  way  as  other  body  func- 
tions. Tissue  changes  occur  in  all  parts  of  the  body,  but  those  metabolic 
activities  with  which  we  are  chiefly  concerned  may  be  traced  to  the  muscles 
as  the  seat  of  the  great  majority  of  oxidative  processes.  The  liver  is  also 
to  a  large  extent  concerned  in  metabolism,  both  nitrogenous  and  carbona- 
ceous. It  is  not  necessary  that  the  muscles  be  excited  to  perceptible  con- 
traction in  order  to  affect  metabolic  changes.  Through  the  innervation  of 
the  muscles,  oxidation  is  controlled  and  may  be  greatly  increased  by  hot  or 
cold  applications,  without  visible  contractions.  This  conclusion  was  arrived 
at  by  Roehrig  and  Zuntz  who  further  confirmed  their  opinion  by  experiments 
upon  animals  "in  which  the  innervation  of  the  muscles  was  held  in  obeyance 
by  "arrow  poison.  In  such  animals  tissue  change  was  not  only  not  increased 
by  cold,  but  was  even  reduced  one-half."2  Other  stimuli  than  cold  also 
aiFect  tissue  changes.  The  relative  value  of  various  cutaneous  stimuli,  vary- 
ing degrees  of  heat  and  the  quantitative  response  of  metabolism  is  best 
studied  with  carbonaceous  metabolism  (q.  v.). 


Strasser  conducted  two  series  of  experiments  at  different  times.  In  the 
first  series  two  young  men  were  selected  as  subjects.  The  daily  ration, 
urine  and  feces  were  carefully  measured,  and  from  chemical  analyses  and  esti- 
mations from  these  the  results  were  obtained.  The  procedures  used  were 
such  as  would  ordinarily  be  administered  to  patients.  In  the  second  series 

1  Das  Verhalten  des  Stoffwechsels  bei  hydratischer  Therapie — Fortschritte  der  Hydrother- 
apie.  Festschrift  zum  Vierzigjahrigen  Doctorjubilaum  deS  Prof.  Dr.  W.  Winternitz,  herausge- 
K^ben  von  Dr.  A.  Strasser  und  Dr.  B.  Buxbaum,  Wein,  1897. 

2  Baruch — Hydrotherapy,  p.  80. 


NITROGEN  ECONOMY 


65 


a  single  individual  was  chosen.  In  this  series  the  intake  upon  a  standard 
diet,  also  the  output  in  feces  and  urine  was  measured  for  five  days  in  order 
to  establish  the  normal  quantities  of  the  various  constituents  for  the  indi- 
vidual under  experiment.  "The  bath  period  lasted  three  days.  On  each 
day  the  man  received  in  the  morning  at  8  o'clock  a  friction  at  14°  R  (63.5° F.) 
Forenoons  at  11:30  a.  m.  a  general  cold  rain  bath  with  moving  fan  douche, 
and  afternoons  a  half  bath  at  22°  cooled  to  18U  K.  (81.5°  to  72.5°  F.)  of  fcur 


Fig.  18.  Showing  the  effect  of  cold  treatment  on  fecal  and 
urinary  nitrogen— reveals  a  heightened  assimulation  of 
proteid.  (Strasser) 

minutes  duration.     Moderate  exercise  followed  each  procedure,  as  much  as 
seemed  necessary  for  warming,  i.  e.,  the  attainment  of  a  gocd  reaction." 
The  results  of  the  first  work  as  tabulated  by  Strasser  are  as  follows: — 

1.  Increase  of  nitrogen  metabolism,  i.  e.,  increase  of  the  nitrogen  excre- 
tion in  the  urine;  a  simultaneous  decrease  in  fecal  nitrogen. 

2.  Absolute  and  relative  increase  in  the  excretion  of  urea. 

3.  High  absolute  increase  in  the  excretion  of  uric  acid,  with  relative  pro- 
portion almost  unchanged. 

4.  High  absolute  and  relative  increase  in  phosphorus  excretion. 

5.  Small  relative  fluctuations  in  the  ammonia  excretion. 

6.  Decrease  in  the  sum  of  the  extractives  to  a  minimum. 

The  results  in  the  second  series  of  experiments  entirely  confirmed  the 
findings  in  the  first,  and  are  of  the  same  general  character. 

Nitrogen  Economy.  The  excretion  of  nitrogen  (Fig.  18)  on  the  first  bath 
day  was  increased  8.3  per  cent  over  the  average  of  the  preperiod;  a  maxi- 
mum increase  of  11.4  per  cent  was  reached  on  the  second  day,  and  on  the 
last  6.0  per  cent,  thus  averaging  8.6  per  cent.  The  increase  continued 


Fig.  19.     Showing  relative  increase  of  urea  and  the  phos- 
phates and  relative  decrease  of  ammonia.     (Strasser) 


UREA  AND  AMMONIA  67 

throughout  the  afterperiod.  In  the  two  first  cases  the  average  increase 
was  respectively  10  and  16.4  per  cent.  The  fecal  nitrogen  shows  a  corres- 
ponding decrease.  The  subject  of  the  experiment  remained  practically  in 
nitrogen  balance  throughout  the  experiment.  The  decrease  in  fecal  nitrogen 
is  to  be  explained  by  an  increased  absorption  of  proteid. 

The  tonic  influence  of  the  reaction  to  cold  procedures  brings  about  an 
increased  digestive  efficiency,  hastens  the  processes  of  absorption  and  assimu- 
lation  and  renders  them  more  complete.  Clinical  observations  have  also 
established  the  fact  that  hydriatic  treatment  properly  suited  to  the  patient's 
reactive  ability  decidedly  and  enduringly  enhances  assimulation. 

Urea  and  Ammonia.  In  Strasser's  experiments  there  was  an  absolute 
increase  of  urea  in  all  cases.  In  the  second  series  this  increase  averaged  12 
percent  during  the  bath  period  and  6.5  per  cent  during  the  after  period.  In 
the  first  series  the  greatest  increase  in  the  two  cases  was,  respectively,  18 
and  25  per  cent  and  the  averages  10  and  21.1  per  cent.  Relative  to  the  total 
nitrogen  there  was  also  an  increase  as  graphically  shown  in  Fig.  19.  From 
an  average  proportion  of  86.9  per  cent  of  the  total  nitrogen  in  the  preperiod, 
the  nitrogen  content  of  urea  rose  to  a  maximum  height  on  the  third  bath 
day  of  92.5  per  cent  of  the  total  nitrogen. 

Ammonia  being  a  precursor  of  urea  and  both  being  derived  from  proteid, 
it  might  be  expected  that  its  amount  would  bear  some  definite  relation  to 
the  amount  of  urea  excreted.  In  the  first  cases  there  was  both  an  absolute 
and  relative  increase  in  the  excretion  of  ammonia.  The  absolute  increase  in 
one  case  reaching  as  high  as  52.5  per  cent  and  averaging  42  per  cent  in  one 
and  36  per  cent  in  the  other.  In  the  afterperiod  one  sank  to  33  per  cent 
below  the  level  of  the  preperiod  and  in  the  other  it  remained  30  per  cent 
higher  than  in  the  preperiod.  In  the  second  series  it  sank  to  normal  in  the 
afterperiod.  Relative  to  the  total  nitrogen,  the  increase  was  less  than  might 
be  expected  and  in  the  second  series  there  was  even  a  slight  relative  decrease. 
Strasser  concludes  that  organic  acids  ordinarily  derived  from  proteid  by 
incomplete  oxidative  processess  and  which  so  powerfully  contribute  to  less- 
ening the  alkalinity  of  the  blood,  have,  under  the  influence  of  the  thermic 
stimulus,  been  burned  up  into  carbon  dioxide  and  water.  This  decreased 
amount  of  organic  acids  would,  he  reasons,  require  less  alkali  (ammonia) 
for  their  neutralization  and  so  lessen  the  relative  amount  of  the  latter  formed.  3 

Uric  Acid  and  Purin  Bases.  The  accepted  theries  of  nuclein  metabolism 
are  perhaps  too  well  known  to  need  explanation  here.  An  increase  in  purin 
excretion  may  arise  from  either  endogenous  or  exogenous  purins.  That  the  in- 
creased excretion  of  uric  acid  is  due  to  heightened  activity  and  breaking  up  of 
the  leucocytes  and  therefore  bears  a  definite  relation  to  the  leucocy tosis  which 
always  accompanies  the  reaction  to  cold  procedures,  can  be  correct  in  part 

3  It  would  seem,  however,  that  the  small  relative  increase  of  ammonia  is  due  to  the  relatively 
more  complete  conversion  of  ammonium  carbonate  into  urea,  its  end  product.  As  a  product  of 
proteid  metobolism  it  is  subject  to  increased  oxidation  in  common  with  other  nitrogen  derivatives, 
a  larger  relative  increase  is  prevented  by  the  increased  vigor  of  hepatic  activity  tending  to  push 
the  change  beyond  ammonium  carbonate  to  the  formation  of  urea. 

Inorganic  acids  require  alkali  for  their  neutralization  as  well  as  organic  acids  and  the  former 
are  not  only  not  decreased  in  amount  but  are  actually  increased.  For  further  discussion  of  the 
requirement  of  organic  acids  for  ammonia  and  fixed  alkali  see  Graham  Lusk— Metabolism  in  Dia- 
betes— Journal  American  Medical  Association,  December  17,  1910. 


68  NITROGENOUS  METABOLISM 

only.  The  excreted  purins  must  of  necessity  come  from  all  the  nuclear 
nitrogen  of  the  body  as  well  as  from  the  leucocytes.  The  more  complete 
oxidation  of  exogenous  purins  and  the  hastening  of  their  excretion  may  also 
account  for  the  increase  in  uric  acid. 

The  results  obtained  by  different  experimenters,  all  agree  as  to  the  abso- 
lute increase  in  uric  acid  excretion  under  the  influence  of  thermic  procedures. 
It  runs  parallel  with  the  excretion  of  urea.  In  Strasser's  experiments  there 
was  an  immediate  increase  of  uric  acid  on  the  first  bath  day,  which  reached  a 
maximum  of  25  per  cent  on  the  third  bath  day  and  an  average  of  22  per 
cent  during  the  entire  bath  period.  The  increase,  though  somewhat  less  in 


Fig.  20.     Showing  effect  of  cold  treatment  on  the  oxidation 
of  purins.     (Strasser) 

per  cent,  continued  throughout  the  entire  afterperiod  at  an  average  height 
of  12.7  per  cent  above  the  level  of  the  preperiod.  The  results  in  the  two 
cases  of  his  first  series  entirely  coincided  with  this.  In  these  cases  the 
increase  in  the  total  purins  averaged  10.4  per  cent  during  the  bath  period  and 
even  a  higher  stage  was  reached  and  maintained  during  the  entire  three-day 
afterperiod. 

Relative  to  the  total  nitrogen  there  was  also  a  slight  increase.     Of  100 
parts  of  total  nitrogen  the  nitrogen  of  the  uric  acid  constituted  1.52  per  cent 


PURINS  69 

in  the  preperiod,  1.71  per  cent  in  the  bath  period  and  1.68  per  cent  in  the 
afterperiod. 

Of  particular  interest  in  connection  with  nuclein  metabolism  is  the  behavior 
of  the  purin  bases.  As  the  uric  acid  excretion  increases  in  amount  the  purin 
bases  progressively  decrease,  until  on  the  third  bath  day  the  entire  purin 
excretion  consists  of  uric  acid,  the  bases  having  wholly  disappeared.  At 
the  close  of  the  treatment  the  purin  bases  again  rise,  to  reach  on  the  third 
day  of  the  afterperiod,  the  height  of  the  preperiod.  This  change  in  the 
proportion  of  the  two  constituents  of  purin  excretion  is  graphically  shown 
in  Fig.  20.  Letting  100  per  cent  represent  the  total  purin  nitrogen,  85.5  per 
cent  appears  as  uric  acid  and  14.5  per  cent  as  purin  bases.  On  the  bath  days 
the  per  cent  of  uric  acid  rises  to  96,  then  to  98  and  finally  to  100  per  cent. 
The  nitrogen  content  of  the  bases  sinks  to  4,  then  to  2  and  finally  to  0  per 
cent. 

With  the  composition  of  uric  acid  and  the  bases  in  mind,  the  explanation 
of  the  above  changes  is  not  difficult.  Uric  acid  is  trioxypurin,  while  the 
bases  all  contain  less  oxygen,  being  mostly  mono-  or  dioxypurin  with  amine 
or  hydrocarbon  side  groups.  Uric  acid  is  therefore  the  most  highly  oxidized 
of  the  purin  bodies.  It  is  plain  to  be  seen  that  the  stimulus  of  the  hydriatic 
procedures  has  resulted  in  oxidation  of  the  bases  to  uric  acid,  a  distinct 
cumulative  effect  being  manifest  by  the  progressive  completeness  of  this 
oxidation,  until  on  the  third  bath  day  no  bases  are  left,  all  purin  nitrogen 
appearing  as  uric  acid. 

This  result  is  of  no  little  importance  in  the  treatment  of  the  gouty  diathe- 
ses. With  a  kidney  permeable  to  uric  acid  as  it  is  in  uncomplicated  gout, 
the  purins  should  come  to  both  complete  oxidation  and  complete  excretion. 
The  increase  in  the  alkalescence  of  the  blood  and  body  tissues  also  resulting 
from  cold  applications  greatly  favors  these  changes. 

The  condition  in  uratic  diathesis,  in  reality,  consists  of  an  accumulation  of 
all  the  purin  bodies  (uric  acid  plus  bases).  Because  of  this  Kolisch  proposed 
the  term  "purin  diathesis"  instead  of  uric  acid  diathesis.  The  excretion  of 
the  bases  exercises  a  poisonous  effect  upon  the  kidneys,  and  the  altered  kid- 
ney is  in  turn  less  capable  of  excreting  basic  purins.  This  vicious  circle 
would  be  done  away  with,  were  the  bases  excreted  in  a  mpre  completely 
oxidized  state,  i.  e.,  as  uric  acid.  As  remarked  by  Strasser,  tonic  hydro- 
therapy  breaks  through  this  vicious  circle  and  completely  changes  the  aspect 
of  purin  auto-intoxication.  The  excretion  of  a  waste,  not  as  such,  but  in 
an  altered  and  less  toxic  state  may  be  considered  "the  removal  of  poison 
par  excellence." 

Extractives.  A  summary  of  the  relation  of  the  nitrogenous  extractives  to 
the  total  nitrogen  shows  that  they  constitute  respectively  3.86  per  cent  in 
the  preperiod,  2.17  per  cent  in  the  bath  period  and  0.56  per  cent  in  the  after- 
period.  As  already  mentioned,  on  the  third  bath  day  they  disappear  entirely 
and  urea,  uric  acid  and  ammonia  claim  the  whole  nitrogen  for  themselves. 

Phosphoric  Acid.  The  phosphorus  of  the  urine  arises  from  certain  pro- 
teids  in  common  with  nitrogen  and  hence  gives  an  added  index  to  the  pro- 
cesses of  proteid  metobolism.  Strasser's  experiments  reveal  an  increased 


70 


NITROGENOUS  METABOLISM 


absorption  of  phosphorus  as  well  as  of  nitrogen,  as  shown  by  the  decrease  in 
fecal  phosphorus  during  the  bath  period  and  an  equal  and  simultaneous 
increase  in  urinary  phosphorus.  The  absolute  increase  in  the  phosphoric 
acid  of  the  urine  reached  a  maximal  height  of  28  per  cent  on  the  second  bath 
day.  Compared  with  the  total  nitrogen,  there  is  also  a  relative  increase  as 
shown  in  Fig.  19.  This  relative  increase  may  be  accounted  for  by  the  fact 
that  phosphorus  comes  from  lecithin  as  well  a?  certain  proteids.  In  the  first 
experiments  the  relative  increase  lasted  throughout  the  whole  of  the  after- 
period.  The  increased  elimination  of  phosphoric  acid  accounts  for  the  effect 


Fig.  21.     Showing  effect  of  cold  treatment  on  the  alkaline 
and  earthy  phosphates.     (Strasser) 

of  cold  treatment  in  increasing  the  alkalinity  of  the  blood  by  decreasing  the 
per  cent  of  acid  phosphate  contained  in  it.  It  is  significant  that  only  the 
more  labile  phosphates  take  part  in  the  increase.  This  increase  in  urinary 
}  hosphorus  is  wholly  in  the  alkaline  phosphates,  the  earthy  phosphates 
remain  unchanged  (Fig.  21). 

Sulphates  and  Chlorides.    The  sulphur  of  the  urine  also  comes  from  pro- 
teid  substances  and  the  urinary  sulphates  are  therefore  another  end  product  of 


EFFECTS  OF  HEAT  71 

proteid  metabolism  and  would  increase  with  nitrogen.  The  average  increase 
was  10.4  per  cent  during  the  bath  period,  which  height  was  maintained  dur- 
ing nearly  the  whole  of  the  afterperiod.  The  increase  in  the  sulphates  was 
almost  entirely  in  the  mineral  sulphates,  the  ethereal  sulphates  suffering 
but  a  trifling  change.  This  might  be  expected  since  more  complete  diges- 
tion and  assimulation  of  proteid,  together  with  completer  oxidation,  would 
tend  to  decrease  putrefactive  changes  and  so  lessen  the  relative  amount  of 
ethereal  sulphate. 

The  increase  in  the  excretion  of  sodium  chloride  was  chiefly  on  the  first 
bath  day  (15  per  cent)  and  did  not  outlast  the  bath  period.  The  excretion 
of  sodium  chloride  in  oadema  is  a  matter  of  no  little  importance.  In  this  con- 
dition hydriatic  applications  produce  an  increase  in  chloride  excretion  in  two 
ways:  first,  by  increasing  the  absorption  of  intestinal  fluid  and,  second,  by 
stimulating  kidney  activity. 

Effects  of  Heat 

The  reported  researches  regarding  the  effects  of  heat  upon  metabolism 
are  somewhat  conflicting  in  their  results.  This  is  doubtless  due  to  differ- 
ences in  the  mode  of  application,  the  intensity,  duration  and  frequency  of 
repetition  of  the  treatment  as  well  as  in  the  reactive  response  of  the  organ- 
ism. Formanek  observed  that  a  single  hot  bath  scarcely  changed  the  nitro- 
gen but  that  after  two  or  more  such  baths  on  successive  days  there  occurred 
a  decided  increase  of  nitrogen  elimination.  It  would  seem  that  a  single  hot 
bath,  if  not  too  prolonged,  should  decrease  the  elimination  of  nitrogen  for 
the  time-being,  as  a  result  of  the  atonic  reaction  and  the  lessened  amount  of 
water  excreted  by  the  kidney. 

In  general  this  agrees  with  the  results  obtained  by  two  different  ob- 
servers4 one  working  with  the  Turkish  bath  and  one  with  the  Russian  bath. 

Effects  of  Turkish  bath  at  122°  F.  for  50  minutes 

Day  before  Bath  Day  of  Bath 

Amount  of  Urine  24  hours 1567.  c.  c. 950.  c.  c. 

Specific  Gravity 1018.8 1027. 

Urea 45.47  gm 39.9  gm 

Uric  Acid 0.683  gm 0.860  gm 

Effects  of  Russian  bath  at  113°  F.  for  25  minutes 

Day  before  Bath  Day  of  Bath 

Amount  of  Urine  24  hours 1683.  c.  c.       900.  c.  c. 

Specific  Gravity 1021 ..1027. 

Urea 52.68  gm 38.7  gm 

Uric  Acid 0.858  gm._  0.980  gm 

Bastels,  Naunyn  and  Schleich  found  an  increase  of  urea  and  total 
nitrogen  excretion  which  later  showed  diminution.  It  is  altogether  possible 
that  these  opposite  results  may  also  be  accounted  for  by  the  differences  in 
amount  of  water  ingested  by  the  subjects  during  the  respective  experiments. 
Loss  of  water  through  sweating  decreases  the  tissue  fluids  and  therefore  the 
urinary  solvent  if  this  loss  is  not  replaced  by  water  drinking.  It  has  been 

4     Hinsdale— Hydrotherapy,  pp.  22,  23. 


72  NITROGENOUS  METABOLISM 

shown  by  Hawk  5  that  copious  water  drinking  increases  the  excretion  of  nit- 
rogen in  the  form  of  urea  due  to  the  washing  out  from  the  tissues  of  pre- 
formed urea.  He  also  observed  a  greater  phosphorus  excretion.  The  maxi- 
mum increase  occurred  regularly  on  the  second  day  of  the  experiment. 

The  secondary  diminution  in  the  nitrogen  excretion  observed  by  Schleich 
would  tend  to  show  that  the  metabolized  nitrogen  in  the  case  of  hot  baths 
comes  more  from  the  tissue  albumen  than  from  any  increase  in  the  intestinal 
absorption  of  proteids. 

In  case  prolonged  hot  applications  increase  the  efficiency  of  absorption, 
there  should  be  a  gradual  return  of  the  curve  of  increased  excretion  to  the 
normal.  Instead  of  this,  lessened  excretion  occurs  in  an  effort  to  restore 
the  nitrogen  balance.  This  also  agrees  with  clinical  experience.  A  course 
of  hot  baths  unaccompanied  by  the  tonic  of  cold  applications  results  in  loss 
of  weight.  It  is  true  this  is  largely  a  loss  of  fat,  but  the  tissue  proteids  are 
also  concerned  in  the  increased  oxidation. 

All  observers  seem  to  agree  that  the  excretion  of  uric  acid  is  increased  by 
hot  baths.  This  being  true,  both  hot  and  cold  baths  should  be  useful  in  gout. 

5    University  of  Pennsylvania  Medical  Bulletin,  1905. 


CHAPTER  XII 

RESPIRATION,  RESPIRATORY  CHANGES  AND 
CARBONACEOUS  METABOLISM 

In  the  previous  chapter,  we  have  considered  tissue  change  solely  from  the 
standpoint  of  proteid  metabolism  and  chiefly  as  regards  the  nitrogenous 
moiety.  There  remains,  of  course,  a  certain  amount  of  carbohydrate  when 
urea  is  split  off  from  the  proteid  molecule,  also  the  carbohydrate  taken  as 
such  and  the  fat,  all  of  which  contain  no  nitrogen.  Their  metabolism  is  so 
intimately  associated  with  respiratory  interchanges  that  we  shall  consider 
them  together;  the  respiratory  excretion  being  quite  as  much  a  guide  to 
these  changes  as  is  renal  excretion  to  nitrogenous  changes. 

We  have  noted  that  all  sorts  of  stimuli  applied  to  the  skin  produce  more 
or  less  pronounced  vasomotor  and  cardiac  changes,  through  reflex  action. 
The  respiration  is  more  readily  affected  by  cutaneous  stimuli  than  is  any 
other  function.  One  of  the  most  efficient  means  of  resuscitating  the  new 
born  infant  is  the  use  of  heat  and  cold.  The  same  method,  i.  e.,  the  alter- 
nate application  of  heat  and  cold  to  the  chest,  is  scarcely  less  effective  in 
the  adult.  The  sudden  application  of  either  extreme  heat  or  cold,  especially 
if  accompanied  by  percussion,  produces  an  initial  deep  respiration,  which  is 
almost  as  suddenly  interrupted,  this  being  followed  by  other  spasmodic 
efforts,  so  that  the  respiration  assumes  a  staccato  type.  With  prolonged 
applications  of  either  heat  or  cold,  the  respiration  soon  becomes  regular,  the 
rate  and  depth  depending  upon  the  temperature  of  the  application. 

Kellogg  records  the  following  experiments  l  as  illustrative  of  the  effect  of 
thermic  stimuli  upon  the  volume  of  tidal  air.  To  a  subject  whose  tidal  air 
measured  28  cubic  inches,  a  wet  sheet  rub  at  40°  F.  was  administered.  Im- 
mediately after  the  treatment,  the  tidal  air  measured  35  cubic  inches,  an 
increase  of  nearly  26  per  cent. 

To  another  subject,  with  an  initial  tidal  air  volume  of  33  cubic  inches,  a 
cold  mitten  friction  was  administered  at  45°  F.  Immediately  after,  the  tidal 
air  measured  51  cubic  inches,  an  increase  of  55  per  cent. 

In  a  third  subject,  the  amount  of  tidal  air  before  the  treatment  was  27 
cubic  inches.  A  wet  sheet  pack  wrung  from  water  at  45°  F.  was  applied  and 
continued  for  one  hour.  After  the  initial  warming,  the  pack  was  kept  at 
the  neutral  stage.  Two  minutes  after  the  sheet  was  applied,  the  volume  of 
tidal  air  was  36  cubic  inches,  an  increase  of  33 J  per  cent.  In  15  minutes  it 
was  33  cubic  inches.  The  volume  gradually  decreased  until  at  the  end  of  the 
hour  it  was  28  cubic  inches.  During  the  entire  period,  there  was  an  average 
increase  of  18£  per  cent. 

1    Rational  Hydrotherapy,  pp.  1122,  1133. 


74  CARBONACEOUS  METABOLISM 

In  a  fourth  subject,  a  heating  compress,  wrung  from  ice  water  was  applied 
to  the  chest  only.  The  tidal  air  immediately  rose  from  507  c.  c.  to  751  c.  c., 
an  increase  of  48  per  cent.  At  the  end  of  20  minutes  the  tidal  air  measured 
604  c.  c.,  20  per  cent  more  than  at  the  beginning.  The  average  increase 
was  170  c.  c.,  or  33  per  cent. 

Another  subject,  whose  tidal  air  was  43  cubic  inches,  was  immersed  in  a 
hot  bath  at  108°  F.  After  12  minutes  the  tidal  air  had  decreased  to  27  cubic 
inches  or  a  decrease  of  37.2  per  cent.  Ten  minutes  after  the  bath,  it  had 
risen  to  33  cubic  inches;  30  minutes  after,  to  37  cubic  inches.  The  loss 
in  the  volume  of  respired  air  amounted  to  37£  per  cent. 

Brief,  sudden  applications  of  cold  produce  spasmodic  respiration.  The 
reaction  to  cold  applications  is  accompanied  by  a  slowed  rate  and  greater 
depth  of  respiration,  as  shown  by  the  above  experiments.  The  rate  is  slowed 
and  the  amplitude  of  movement  increased  in  proportion  to  the  completeness 
of  reaction. 

Warm  baths  or  hot  moist  applications  to  the  chest  increase  the  ease  of 
respiration,  at  the  same  time  somewhat  increasing  the  rate.  Long,  hot 
baths  produce  frequent,  shallow  breathing.  Here  again  the  conflicting 
results  which  have  been  reported  are  doubtless  due  to  varying  modes  of 
applying  the  hot  applications,  also  to  the  degree  and  duration  of  the  heat. 
The  inhaling  of  dry  air  produces  difficult  breathing.  This  may  be  due  to  the 
drying  of  the  membranes,  thus  compelling  deeper  or  more  frequent  respira- 
tion to  obtain  the  same  amount  of  oxygen.  Inhalations  of  steam  greatly 
facilitate  respiration.  It  is  decidedly  beneficial  in  almost  all  forms  of  dys- 
pnoea. The  moisture  favors  gaseous  interchange,  while  the  heat  dilates 
the  blood  vessels,  thus  increasing  the  surface  presented  for  the  interchange. 
The  steam  may  be  made  the  vehicle  of  some  volatile  drug,  so  enhancing  its 
antidyspnoeic  properties. 

Having  considered  the  physical  changes  in  respiration,  we  may  pass  to  the 
alterations  observed  in  the  chemical  activities  of  the  respiratory  function. 
Since  it  has  been  shown  that  both  hot  and  cold  baths  increase  nitrogenous  . 
metabolism,  we  might  expect  the  same  effects  upon  the  oxidation  of  carbon- 
aceous material.     This  is  precisely  what  occurs. 

Rubner2  (1903)  has  given  us  some  observations  which  are  of  a  very  practi- 
cal nature,  since  the  results  obtained  were  after  hot  and  cold  applications 
given  as  they  are  ordinarily  applied  in  practice.  The  following  table  shows 
the  effect  of  short  baths  upon  the  consumption  of  oxygen  and  the  elimina- 
tion of  carbon  dioxide:— 

Bath  at  Volume  of  Air           CO-2  O2  Reap  Quot. 

61n  F.  plus  22.9$        plus  64.8%  plus  46.8  #  0.86  1.00 

86°  F.                          "7.3             "     31.0  "    16.2  0.95  0.93 

91°  F.                          "       1.8        minus    1.8  "      6.2  0.87  0.90 

104    F.                          "16.1             "3.9  "      3.2  0.86  0.90 

lllc  F.                          "     18.8           plus  32.1  "     17.3  0.86  1.00 

H.  Winternitz  (1899)  in  seven  experiments  upon  the  same  individual, 
observed  that,  hot  baths  continued  30  minutes  produce  during  that  time,  an 

2     Archiv  fur  Hygiene,  1903,  Bd.  46. 


LAWS  OF  RESPIRATORY  EFFECTS  75 

average  increase  in  the  consumption  of  oxygen  amounting  to  78  per  cent  and 
in  COa  elimination  of  91  per  cent.  Observations  made  on  an  average  nearly 
an  hour  after  the  bath,  still  revealed  an  increase  of  22  per  cent  in  the  oxygen 
consumed  and  16  per  cent  in  CO2  excreted.  Rubner  has  shown  that  meta- 
bolism is  at  a  minimum  under  temperatures  from  91.4°  to  95°  F.  (33°  to  35° 
C.).  A  fall  of  every  1°  C.  in  the  surrounding  temperature,  increases  meta- 
bolism by  2  or  3  per  cent. 

From  the  above  observations,  we  may  deduce  the  law  that  applications 
below  the  skin  temperature  increase  respiratory  changes  in  proportion  to 
the  degree  of  cold.  Neutral  temperatures  exert  but  little  influence.  Tem- 
peratures above  that  of  the  skin  surface  again  increase  the  respiratory  func- 
tion in  proportion  to  the  degree  of  heat. 

Rubner3  found  in  his  experiments  that  a  douche  produced  more  than  double 
the  change  produced  by  a  bath  at  the  same  temperature,  each  continued  for 
the  same  length  of  time,  viz.,  3J  to  5  minutes.  The  accompanying  table 
shows  the  increase  in  per  cent. 

Douche  at  61°  F.  Bath  at  61°  F. 

Volume  of  Air. _                           plus  54.5  #•  ..  ,.plus22.95v 

C02  Exhaled  _.                                           -    "  149.4  .    "     64.8 

O  Consumed .    "110.1  46.8 

These  observations  prove  the  immense  advantage  of  mechanical  stimuli 
combined  with  thermic  and  also  of  exercise  following  hydriatic  treatment, 
especially  when  taken  in  the  open  air.  A  swimming  bath  or  cold  rubbing 
bath  produces  more  decided  tissue  change  than  quiet  immersion  for  the  same 
reason.  The  lung  gymnastics  produced  by  hydriatic  applications  are  by  no 
means  the  least  important  factor  in  the  results  produced  by  hydrotherapy. 
This  seems  to  be  the  effect  of  first  importance  in  the  treatment  of  broncho- 
pneumonia  in  infancs  and  children. 

3    Ibid.,  p.  390. 


CHAPTER    XIII 


MUSCULAR  CAPACITY 

The  restorative  effect  of  baths  in  relieving  the  sense  of  fatigue,  and  the 
tonic  effect  of  the  cold  douche  or  spray  in  overcoming  the  effects  of  fatigue, 
are  familiar  to  all  who  are  acquainted  with  the  practical  application  of  hy- 
driatic  procedures.  These  effects  are  extensively  used  by  athletes  in  over- 
coming the  exhaustion  of  severe  or  prolonged  exertion.  And  medically  con- 
sidered, they  are  by  no  means  the  least  important  of  the  results  obtained 
by  hydriatic  applications. 

In  1892  and  1893  Vinaj  and  Maggiori 1  reported  a  series  of  experiments 
undertaken  to  show  the  effect  of  hydriatic  measures  upon  the  capacity  of 
the  muscles  for  work  and  their  resistance  to  fatigue.  These  investigations 
were  made  with  Mosso's  ergograph.  This  instrument  is  so  constructed  as 
to  hold  the  hand  and  forearm  stationary  in  the  body  of  the  apparatus,  while 


Fig.  22.    Fatigue  curve  of  right  hand,    (a)  Normal;  (b)  after 
bath  at  50°  F.  for  15  seconds. 

one  finger  is  left  free  for  flexion  and  extension.  The  forefinger,  or  middle 
finger,  is  usually  employed  so  that,  by  means  of  a  cord  over  a  pulley,  it 
raises  and  lowers  a  weight.  This  is  kept  up  until  the  muscles  are  fatigued 
and  unable  to  contract  longer.  Their  experiments  were  done  with  a  weight 
of  three  or  four  kilograms,  raised  every  two  seconds. 

In  one  experiment  (Fig.  22  a),  the  middle  finger  of  the  right  hand  was,  un- 
der normal  conditions,  able  to  execute  50  contractions,  representing  a  work 
of  5.139  kilogrammeters.  After  a  cold  bath  at  50°  F.  for  15  seconds,  the 
same  group  of  muscles  executed,  before  fatigued,  74  contractions,  repre- 

1     Blatter  fur  klinische  Hydrotherapy. 


EFFECTS  OF  COLD  77 

senting  a  work  of  9.126  kilogrammeters  (Fig.  22  b). 

A  graduated  bath  beginning  at  96°  F.  and  ending  at  68°  F.  increased  the 
number  of  contractions  from  39,  representing  a  work  of  3.603  kilogrammeters 
to  87  contractions,  the  equivalent  of  9.349  kilogrammeters  of  work  (Fig.  28). 

When  the  muscles  are  already  fatigued  from  active  work,  by  cold  appli- 


Fig. 23.    Fatigue  curve  (a)  before  and  (b)  after  graduated 
bath,  96"  to  68?  F. 


a 


Fig.  24.  Effect  of  work  and  graduated  bath  upon  fatigue 
curve.  (a)  Normal,  (b)  after  active  work,  and  (c) 
after  work  followed  by  bath. 

cations  they  may  be  restored  to  their  usual  power.     This  restorative  effect 
is  well  ilustrated  in  Figs.  24  and  25. 

In  Fig.  24  the  first  tracing  (a)  represents  the  fatigue  curve  of  the  nor 
muscle.      The  second  (b)  is  the  fatigue  curve  taken  following  active  work, 
i.  e.,  at  a  time  when  muscular  capacity  has  already  been  partially  exhaustec 
The  third  tracing  (c)  shows  the  restorative  effect  of  a  graduated  bath  giver 


78  MUSCULAR  CAPACITY 

following  the  fatigue  of  active  work.     In  the  case  of  the  cold  wet  sheet  rub 
following  fatigue  (Fig.  25  c)  the  muscular  capacity  has  been  increased  to  a 
point  even  above  the  normal. 
To  what  are  these  tonic  and  restorative  effects  due?    This  question  may 


a  b  c 

Fig.  25.     Effect  of  labor  and  cold  wet  sheet  rub  upon  fatigue 
curve,    (a)  Normal,  (b)  after  labor,  and  (c)  after  labor 
followed  by  wet  sheet  rub. 


Fig.  26.  Effect  of  simple  warm  bath  and  of  warm  douche 
on  fatigued  muscles,  (a)  Muscular  fatigue  followed  by 
warm  bath,  (b)  after  fatigue  only,  and  (c)  after  fa- 
tigue followed  by  warm  douche. 

be  somewhat  difficult  to  answer;  but  it  would  seem  that  the  restoration  of 
the  muscle  to  its  normal  working  power  is  due  to  more  than  one  change. 
Among  these  changes  may  be  mentioned  the  restoration  of  tone  to  the 


LAWS  OF  MUSCULAR  EFFECTS  79 

nerve  and  its  central  cell  brought  about  by  the  cold  application.  It  is  prob- 
ably due  also  to  washing  out  of  the  fatigue  poisvns  consequent  on  the  quick- 
ening of  the  circulation;  and  third  to  the  return  of  the  blood  to  a  condition 
of  more  normal  alkalinity. 

With  hot  baths  the  opposite  effects  prevail.  There  is  a  decided  lessening 
of  the  muscular  capacity,  amounting  in  one  of  Kellogg's  experiments  to  a 
decrease  of  44  per  cent.  His  experiments  cover  a  wide  range  and  are  very 
instructive.  He  used  both  Mosso's  ergograph  and  the  dynomometer;  the 
latter,  a  machine  of  his  own  design.  The  following  table  is  compiled  from 
his  experiments  with  Mosso's  ergograph2  :— 


SUBJECT 

HOT  1 

Age  Weight 

21        140 

26      150 

Initial             Degree 
Strength 

4.994        Spr.  113° 
5.395 

not  stated 

1.312 

D.  115° 

26      151 

8.282 

26      151 

6.371 

Gen.  D.  112° 

26      151 

8.033 

B.  104° 

26      151 

5.817 

26      151 

5.817 

Neutral  bath 

21       140 

5.761 

21       140 

4.791 

Time 

15  min. 


Result 
4.432 


COLD  TREATMENT 

Degree 


5  min.     0.927 


15  min. 
20  min. 


Spr.  60° 
D.  60C 
D.  55° 
D.  60° 

4. 155  Gen.  D.  56° 
4.459 

Gen.  D.  55° 
5.789 

Shal.  B.  65° 
W.  S.  P.  60° 


Time 

10  min. 

1  min. 
15  sec. 

3  min. 
15  sec. 


Result 

6.094 
6.925 
1.527 
11.966 
8.448 


15  sec.     8.642 


2  min. 
20  min. 


7.589 
5.456 


Considering  both  the  dynomometer  and  ergograph  experiments,  there  was, 
after  cold  procedures,  an  average  gain  in  muscular  capacity  of  about  30  per 
cent  and,  after  hot  applications,  an  average  loss  of  30  per  cent  in  the  work 
accomplished.  Cold,  therefore,  increases  the  muscular  working  capacity; 
while  warmth,  not  combined  with  mechanical  effects,  diminishes  muscular 
power.  After  fatigue  a  simple  warm  bath  may  slightly  increase  muscular 
power  although  this  effect  is  not  decided  (Fig.  26,  first  tracing).  Warm 
procedures  when  combined  with  friction  or  percussion,  as  in  douches,  pro- 
duce an  increase  in  muscular  power,  but  to  a  less  extent  than  cold  (Fig. 
26) .  In  practice,  alternate  hot  and  cold  douches,  when  so  given  that  the  hot 
is  short  and  used  only  to  prepare  the  body  for  cold,  produce  the  greatest  in- 
crease in  the  working  power.  Mechanical  effects  alone,  as  massage,  give 
the  least  increase  of  muscular  power. 

The  therapeutic  points  of  practical  importance  which  one  may  gain  from 
the  facts  brought  out  by  the  above  experiments,  are  these:  Hot  applica- 
tions are  useful  in  decreasing  the  tonicity  of  hypertonic  muscles,  lessening 
their  irritability,  and  relieving  either  clonic  or  tetanic  spasm.  The  hot 
leaves  no  bad  after  effects.  Unlike  morphia  or  the  bromides,  it  does  not 
cover  up  or  mask  important  symptoms.  It  does  not  poison  or  anaesthetise 
the  nerve  centers  or  endings. 

In  cold  applications,  properly  graduated  to  suit  the  needs  of  various  con- 
ditions, we  possess  the  most  useful  muscular  stimulant  and  tonic  known  to 

2    Recorded  in  Rational  Hydrotherapy. 


80  MUSCULAR  CAPACITY 

medical  science.  The  stimulating  effects  of  strychnin  are  not  comparable 
with  it.  The  stimulation  produced  by  strychnin  is  not  constant  or  uniform. 
Its  toxic  action  becomes  manifest  in  even  small  doses.  Its  frequent  repe- 
tition soon  wears  out  the  response,  and  depression  results.  When  frequently 
repeated,  the  stimulating  stage  is  of  very  transient  duration  and  later,  is 
absent  altogether.  It  produces  a  feeling  of  exhaustion  or  irritability, 
rather  than  exhilaration.  "On  the  whole,  strychnin  must  be  looked  upon 
only  as  a  temporary  remedy.  It  must  be  remembered  that  it  does  not  in 
any  way  permanently  improve  the  condition  of  the  central  nervous  system, 
nor  does  it  increase  any  of  the  functions  except  reflex  irritability.  It  is 
doubtful  whether  the  permanent  maintenance  of  this  artificially  raised  irri- 
tability is  ever  of  benefit."  3 

3    Sollmann— Pharmacology,  p.  175. 


CHAPTER    XIV 
THE  HEAT  MECHANISM 


All  the  energy  liberated  in  the  body  by  the  decomposition  and  oxidation  of 
food  appears  as  work  or  heat.  It  has  been  calculated  that  about  0.9  of  this 
energy  goes  to  produce  heat  and  0.1  appears  in  the  form  of  work.  Next  to 
the  muscles  in  importance  as  a  source  of  bodily  heat,  is  the  liver.  The  tem- 
perature of  the  blood  in  the  hepatic  vein  is  higher  than  in  any  other  part  of 
the  body.  This  is  doubtless  because  of  the  magnitude  of  metabolic  changes 
which  occur  in  the  liver. 

"On  the  processess  of  metabolism— the  decomposition  and  oxidation  of 
foodstuffs— depend  the  maintenance  of  life.  Hence  all  living  animals  are 
continually  producing  heat  and  imparting  it  to  the  surrounding  bodies;  and 
unless  this  heat  production  is  more  than  counterbalanced  by  loss  of  heat  in 
surface  evaporation,  they  must  have  a  higher  temperature  than  the  surround- 
ing medium,  although  the  difference  may  not  amount  to  more  than  two  or 
three  degrees  in  cases  where  metabolic  processes  are  going  on  sluggishly. 

'  'The  temperature  of  an  animal  is  the  algebraic  sum  of  two  factors — the 
amount  of  heat  produced  and  the  amount  of  heat  lost  in  a  given  time.  If, 
while  the  heat  production  remains  constant,  the  amount  of  heat  imparted 
to  the  surrounding  medium  be  increased,  the  temperature  will  fall.  If,  on 
the  other  hand,  heat  loss  remaining  constant,  heat  production  be  raised,  the 
temperature  will  rise  in  the  same  proportion.  So  the  temperature  may  be 
regulated  by  alterations  in  the  heat  production  or  in  the  heat  loss;  and  if 
the  temperature  is  to  remain  constant,  there  must  be  an  accurate  correlation 
between  the  two  processes. 

Regulation  of  Heat  Production 

"It  has  already  been  mentioned  that,  if  a  frog  or  other  cold-blooded  animal 
be  exposed  to  a  higher  temperature,  its  internal  temperature  will  also  rise. 
If,  at  the  same  time,  we  measure  the  respiratory  interchanges  of  the  frog, 
we  find  that  at  the  higher  temperature,  more  carbon  dioxide  is  evolved  and 
more  oxygen  taken  up,  showing  that  in  this  case  a  rise  of  temperature  in 
the  surrounding  medium  causes  a  rise  in  the  temperature  of  the  frog,  and 
at  the  same  time,  increases  the  activity  of  its  metabolic  changes.  Cooling 
has  the  reverse  effect.  If  a  frog  be  cooled  to  0°  C.,  the  chemical  changes 
in  its  tissues  are  so  reduced  that  it  may  be  kept  alive  for  some  days  in  an 
atmosphere  devoid  of  oxygen.  The  case  is  quite  otherwise  with  warm- 
blooded animals.  Exposure  of  one  of  them  to  a  cold  medium  raises  the 
amount  of  carbon  dioxide  given  off  and  oxygen  taken  in,  while  the  tempera- 
ture of  the  animal  remains  unaltered.  This  power  of  the  animal  to  react  to 


82  THE  HEAT  MECHANISM 

changes  in  the  temperature  of  the  surrounding  medium  is  dependent  on  the 
integrity  of  the  nervous  system  and  its  connection  with  the  muscles.  If  a 
dog  or  rabbit  be  poisoned  with  curare  (which  paralyzes  the  muscle  end-plates), 
or  if  its  spinal  cord  be  divided  just  below  the  medulla,  its  temperature  sinks 
continuously.  It  is  then  found  that  the  animal  reacts  to  changes  in  the  tem- 
perature of  the  surrounding  medium  precisely  like  a  cold-blooded  animal — rise 
of  the  external  temperature  causing  rise  of  the  internal  temperature  and 
increased  elimination  of  C02,  while  a  fall  of  the  external  temperature  has 
the  reverse  effect."  l 

It  has  been  shown  that  metabolism  and  heat  production  are  proportional 
to  the  skin  area  of  the  animal  under  observation.  The  temperature  nerves 
of  the  skin  constitute  the  mechanism  by  which  thermic  impressions  are 
received.  Quantitative  results  as  regards  heat  production  are  therefore 
dependent  upon  the  area  stimulated.  An  animal  whether  of  little  or  much 
weight,  produces  heat  not  according  to  its  weight  but  according  to  the  extent 
of  the  skin  surface  exposed  to  the  surrounding  medium. 

Regulation  of  Heat  Loss 

From  the  standpoint  of  hydrotherapy,  however,  of  more  importance  than 
the  regulation  of  temperature  by  the  production,  is  regulation  by  heat  loss. 
Heat  is  lost  from  the  body  in  three  ways.  Only  the  last  two  of  these  are  of 
any  practical  importance  and  the  third  is  of  the  greatest  utility,  for  it  is 
largely  through  this  avenue  that  febrile  temperatures  are  controlled.  The 
three  ways  are  as  follows: — 

1.  By  the  Urine  and  Feces.      About   3   per   cent  of  the  total  heat  lost 
from  the  body,  leaves  it  with  excretions. 

2.  By  the  Expired  Air.     "The  inspired  air  is  taken  in  at  the  temperature 
of  the  surrounding  atmosphere,  and  contains  only  a  small  amount  of  aqueous 
vapor.     The  expired  air  has  a  temperature  of  about  1°  lower  than  the  body 
temperature,  and  is  saturated  with  water  vapor.     Heat  is  therefore  lost  in 
respiration  in  two  ways:    first,  in  warming  the  inspired  air;  second,  in  the 
evaporation  of  large  quantities  of  water.     These  two  sources  of  loss  consti- 
tute about  20  per  cent  of  the  total  heat  loss. 

3.  By  the  Skin.       "Here  again  the  loss  of  heat  is  affected  in  two  ways: 
first,  by  radiation  and  convection.     By  these  means,  an  interchange  of  heat 
takes  place  between  the  surface  of  the  body  and  surrounding  objects,  tend- 
ing to  cool  the  body  under  ordinary  circumstances  when  the  external  tem- 
perature is  below  98.4°  F.,  or  37°  C.,  or  to  warm  the  body  when  the  external 
temperature  is  higher  than  this,  as  during  the  hot  season  in  the  tropics  or 
in  a  Turkish  bath.     The  amount  of  interchange  of  heat  between  two  bodies 
is  directly  proportionate  to  the   difference  of  temperature    between  them. 
r\  hus,  the  warmer  the  surface  of  the  body  in  comparison  with  that  of  sur- 
rounding objects,  the  greater  will  be  the  amount  of  heat  interchange,  which 
in  this  case  implies  a  loss  of  heat  to  the  body.      Since  very  little  heat  is 
generated  in  the  skin  itself,  its  temperature  is  intimately  dependent  on  the 
amount  of  blood  flowing  through  it,  and  this  in  its  turn  on  the  condition  of 
the  blood  vessels  of  the  skin.      When  these  are  dilated,  there  is  a  constant 

1     Starling- Physiology,  1907.   pp.  500-503. 


HEAT  LOSS  83 

supply  of  warm  blood  from  the  deeper  parts  of  the  body  to  the  skin,  which 
therefore  is  kept  warm  and  feels  warm,  both  subjectively  and  objectively 
Hence  dilatation  of  the  blood  vessels  of  the  skin,  under  normal  circumstances 
brings  about  increased  loss  of  heat.  If,  on  the  other  hand,  the  vessels  are 
constricted,  the  small  amount  of  blood  supplied  to  the  skin  rapidly  becomes 
cooled  and  the  skin  is  also  cool,  and  the  loss  of  heat  small. 

"Second,  by  the  evaporation  of  the  sweat.  In  the  conversion  of  water  into 
watery  vapor,  a  large  amount  of  heat  becomes  latent.  This  principle  is 
made  use  of  in  making  ice,  or  in  cooling  a  bottle  of  water  by  surrounding 
it  with  damp  cloths  which  are  exposed  to  a  draught  of  air  to  facilitate  evap- 
oration. If  the  secretion  of  sweat  is  small,  it  evaporates  as  it  is  secreted, 


H«at  Low  i a  Calorie*  fier  Kvloqram 

Fig.  27.     Rubner's  chart  showing  the  manner  of  heat  loss 
at  different   room   temperatures   in   the   dog.  -  -,    heat 

loss  in  calories  through  evaporation  ofivater,  —        — ,  heat  loss 
in  calories  through  radiation  and  convection. 

and  the  skin  remains  dry.  This  is  spoken  of  as  insensible  perspiration.  If 
the  secretion  be  very  copious,  it  may  be  formed  faster  than  it  can  evapor- 
ate, and  appears  on  the  skin  as  drops  of  sensible  perspiration.  The  forma- 
tion of  sensible  perspiration  depends  then  on  two  factors— the  amount  of 
sweat  secreted,  and  the  rapidity  of  evaporation,  which  latter  again  is  depend- 
ent on  the  amount  of  saturation  of  the  surrounding  atmosphere  with  watery 
vapor. 


84  THE  HEAT  MECHANISM 

"The  loss  of  heat  by  the  skin  amounts  to  about  77  per  cent  of  the  total 
heat  loss,  and  is  therefore  the  most  important  of  all  the  channels  for  the 
discharge  of  heat.  The  regulation  of  the  the  total  heat  loss  is  also  effected 
chiefly  by -changes  in  the  loss  through  the  skin.  The  nervous  channels  by 
which  this  is  carried  out  are  the  vasomotor  and  the  sweat  nerves.  If  the 
external  temperature  be  below  that  of  the  body,  the  loss  by  radiation  and 
convection  may  be  sufficient  to  get  rid  of  the  excess  of  heat  produced.  If, 
however,  the  external  temperature  be  higher  than  that  of  the  body,  radia- 
tion and  convection  will  serve  only  to  warm  the  body  still  further,  and  the 
sole  loss  of  heat  that  can  be  affected  is  by  the  evaporation  of  sweat  (Fig.  27), 
which  is  accordingly,  under  such  circumstances,  secreted  in  large  quantities. 

"Often,  especially  after  severe  muscular  exercise,  radiation  and  convection 
are  not  sufficient  to  carry  off  the  excess  of  heat  produced,  and  hence  there 
is  a  copious  secretion  of  sweat  as  well,  even  though  the  external  tempera- 
ture may  be  cool."  2 

The  relative  values  of  the  different  means  of  heat  loss  are  estimated  by 
Vierordt  as  follows: — 

1.  By  urine  and  feces 1.8  per  cent 

2.  By  expired  air:  warming  of  air 3.5    "       " 

Vaporization  of  water  from  the  lungs 7.2    "       " 

3.  By  evaporation  from  the  skin 14.5    "      " 

4.  By  radiation  and  conduction  from  skin 73.0    "       " 

"So  perfect  is  the  adaptation  of  the  heat  loss  to  the  heat  production,  that 
a  man  may  travel  from  the  poles  to  the  equator,  may  eat  or  fast,  take  exer- 
cise or  rest,  without  causing  any  lasting  alteration  in  his  temperature  of 
1°  C.,  though  violent  exercise  may  induce  in  many  individuals  a  temporary 
rise  of  temperature  of  2°  C."  3 

"We  may  at  present  adopt  the  conservative  view  that  heat  production 
and  heat  dissipation  in  the  body  are  controlled  not  by  a  special  heat-regulat- 
ing apparatus,  composed  of  heat  centers  and  heat  nerves,  but  by  the  co- 
ordinated activity  of  a  number  of  different  centers  in  addition  to  the  volun- 
tary means  already  specified.  The  unconscious  regulation  of  the  body 
temperature  is  effected  chiefly  through  the  following: — " 4 

Heat  Dissipation. 

1.  The  sweat  centers  and  sweat  nerves. 

2.  The  vasoconstrictor  centers  and  their  nerve  fibers  to  the  skin. 

3.  The  respiratory  center. 

Heat  Production. 

1.  The  motor  nerve  centers  and  the  motor  nerve  fibers  to  the  skeletal 
muscles. 

2.  The  quantity  and  character  of  the  food. 

3.  Secretory  and  other  glandular  nerves. 

2  Starling — Physiology,  pp.  504-506. 

3  Starling — Ibid.,  p.  506. 

4  Modified  from  Howell— Physiology,  1908,  p.  866. 


EFFECTS  OF  BATHS  85 

Experiments  in  Heat  Production  and  Elimination 

For  our  purpose,  no  time  need  be  spent  on  experimental  proof  of  the 
effects  of  muscular,  glandular  and  other  vital  activities  on  heat  production 
and  elimination.  We  wish,  however,  to  quote  more  or  less  at  length  the 
experimental  basis  of  the  physiologic  effects  of  hydriatic  applications  upon 
heat  production  and  heat  loss.  Kellogg's  experiments  (Rational  Hydro- 
therapy)  along  this  line  are  very  practical  since  the  tests  were  made  after 
applications  of  the  intensity  and  duration  actually  employed  in  practice. 

W.  was  given  a  cold  percussion  douche  for  30  seconds.  The  change 
in  rectal  temperature  immediately  after  revealed  an  increase  of  nearly  90 
heat  units  and  this  in  spite  of  the  increased  heat  elimination  resulting  from 
the  reaction.  Another  experiment  upon  a  subject  A.  revealed  the  fact  that 
while  quiet  immersion  in  a  bath  at  82°  F.  for  5  minutes  absorbed  heat 
from  the  body,  it  did  not  cause  any  material  increase  in  heat  production 
above  the  normal  amount  or  rate.  When  the  same  subject  was  placed  in 
a  bath  at  77°  F.,  and  rubbed  constantly  during  the  5  minutes,  heat  loss 
was  increased  3  times  and  heat  production  6  times  the  normal  amount. 
P.  was  given  a  short  hot  spray  at  106°  F.  By  means  of  a  bath-tub  calori- 
meter, it  was  estimated  that  heat  production  had  been  decreased  22.7  per 
cent.  By  means  of  a  d'Arsonval  calorimeter,  it  was  shown  that  oiling  the 
skin  decreased  heat  elimination  45  per  cent. 

A  series  of  four  tests  with  the  d'Arsonval  calorimeter,  were  made  upon 
W.  In  a  room  temperature  of  70°  F,  when  placed  in  the  calorimeter,  the 
elimination  of  heat  from  his  body  produced,  as  shown  by  the  anemometer, 
an  air  movement  at  the  rate  of  123  feet  per  minute.  After  an  electric 
light  bath,  sufficient  to  redden  the  skin  without  sensible  perspiration,  the 
air  movement  increased  to  140  feet  per  minute.  After  an  electric  light 
bath  to  profuse  perspiration,  the  rate  of  air  movement  was  170  feet  per 
minute.  After  a  cold  percussion  douche  at  60°  F.  for  2  minutes,  the  air 
movement  was  70  feet  per  minute.  In  10  minutes,  when  reaction  had  taken 
place,  it  was  110  feet  per  minute. 

By  means  of  a  bath-tub  calorimeter,  it  was  ascertained  that  a  certain 
subject  when  immersed  in  water  at  70°  F.  imparted  heat  to  the  water  to 
the  extent  of  raising  its  temperature  0.72°  in  5  minutes.  When  friction 
was  applied,  the  temperature  of  the  water  rose  at  the  rate  of  1.08°  F.  in  5 
minutes,  or  an  increase  of  50  per  cent  in  heat  elimination. 

The  giving  of  copious  enemata  at  70°  F.  at  intervals  of  25  minutes  for  an 
hour  and  a  half,  to  a  subject  S. ,  reduced  the  mouth  temperature  from  98°  to 
96.9°  F.,  and  the  rectal  temperature  from  100°  to  95.2°  F. 

The  drinking  of  seven  glasses  of  lemonade  at  58°  F.  in  the  case  of  M.  pro- 
duced, in  20  minutes,  the  following  changes:— 

Temperature  By  Axilla  By  Mouth  Per  Rectum  On  Epigastrium 

Before  97.7°  98.7°  99.2° 

After  96. 1G  98.0°  98.0° 

It  has  already  been  mentioned  that  for  every  fall  of  1°  C.  in  the  surround- 
ing temperature  there  is  an  increase  of  metabolism  amounting  to  2  or  3  per 


86  THE  HEAT  MECHANISM 

cent.  Rubner  experimenting  with  a  bath  of  one  hour's  duration,  obtained 
the  following  results  in  the  case  of  a  man  weighing  60  kilograms  and  in 
whom  there  was  a  normal  heat  production  of  91  calories  per  hour. 

Effects  of  Bathing  on  Heat  Production 

Temperature  Increased  Increase  of  Metabolism     Total  Effect  During 

of  Bath  Heat  Production  in  Grams  of  Fat  and  After  Bath 

95°  F.  7  calories  0.7  grams  0.7  grams 

86°  77      "  8.0      "  9.0      " 

77°  167       "  18.0      "  22.0       " 

68°  297      "  31.0      "  37.0      " 

59°  407      "  43.0      "  52.0      " 

In  regard  to  the  heat  loss  it  is  estimated  that  in  a  bath  at  86°  F.  the  heat 
loss  is  doubled,  in  a  bath  at  77°  F.  it  is  tripled  and  at  68°  F.  it  reaches  5 
times  the  normal.  It  is  interesting  to  note  that  more  than  half  and  some- 
times as  high  as  two-thirds  of  the  total  heat  loss  in  a  cold  bath  occurs  during 
about  the  first  third  of  the  treatment.  In  a  cold  bath  at  80°  F.  of  15 
minutes  duration  and  with  a  total  heat  loss  of  75  calories,  43  calories  of  this 
heat  loss  occurred  during  the  first  5  minutes.  In  another  case  with  a 
cold  bath  at  63°  F.  of  2£  minutes  duration  and  a  total  heat  loss  of  65  calories, 
nearly  44  calories  of  this  were  lost  during  the  first  minute. 

The  reason  for  the  greater  heat  loss  early  in  the  course  of  a  cold  bath, 
is  doubtless  due  to  the  fact  that  the  body  is  unprepared  to  resist  the  abstrac- 
tion of  heat,  consequently  the  high  heat  loss.  But  very  soon  the  heat  regu- 
lating centers  set  in  motion  vascular  and  other  changes  which  are  tended 
to  economize  the  body  heat  as  far  as  possible,  i.  e.,  resist  heat  loss  as  well 
as  provide  for  increased  heat  production.  The  body  tends  to  resist  the 
abstraction  of  heat  brought  about  by  contact  with  cold  water  by  making 
more  unfavorable  the  conditions  for  heat  elimination. 

The  following  are  some  of  the  results  claimed  by  Otto  PospischI  as  a  result 
of  his  work  as  assistant  to  Prof.  Winternitz. 

Thermic  influences  which  cause  goose-flesh,  decrease  heat  elimination  as 
much  as  38.7  per  cent. 

Partial  cold  wet  rubbing  may  increase  heat  elimination  as  much  as  80  per 
cent,  and  vigorous  friction  in  the  cold  bath  as  much  as  44  per  cent. 

Cold  shower  baths,  with  rest  following,  increase  heat  elimination  25  per 
cent;  with  subsequent  exercise,  the  heat  elimination  is  increased  66.6  per 
cent  over  the  normal. 

Warm  shower  baths  with  cold  fanning  and  rest,  increase  heat  elimination 
60  per  cent. 

Summary 

Heat  Production  (Thermogenesis) 

The  following  are  some  of  the  conditions  and  measures  that  increase  heat 
productions: — 

Vital  activities  such  as, — 

1.  Glandular  activity. 

2.  Muscular   activity. 


SUMMARY  87 

3.  Digestive  activity. 

4.  Mental  activity. 

External  conditions, — 

5.  Reaction  to  cold  applications  (either  long  or  short). 

6.  Low  atmospheric  temperatures. 

7.  High  atmospheric  temperatures. 

The  following  conditions  and  measures  decrease  heat  production:— 

1.  Fasting. 

2.  Sleep  and  rest. 

3.  Reaction  to  short  hot  applications. 

Heat  Elimination  (Thermolysis) 

The  following  conditions  increase  heat  elimination;  the  agents  or  means 
which  produce  these  conditions  are  listed  as  subordinates. 

1.  Dilated  surface  vessels  and  rapid  circulation, — 

a.  Heat. 

b.  Short  cold  (reaction). 

c.  Friction. 

d.  Weak  chemical  irritants. 

2.  Increased  perspiration  (by  evaporation  of  water),— 

a.  Heat. 

b.  Friction. 

c.  Water  drinking. 

3.  Increased  rate  of  respiration. 

More  or  less  prolonged  applications  of  cold,  whether  cold  water  or  cold 
air,  abstract  heat  from  the  body  by  conduction;  but  they  tend  to  make  the 
body  resist  this  effect;  that  is,  it  attempts  to  counteract  heat  elimination. 

Conditions  that  decrease  heat  elimination: — 

1.  Contracted  surface  vessels  and  slowed  circulation  (as  in  goose-flesh). 

2.  Decrease  of  perspiration  (lessened  evaporation) . 

3.  Slowing  of  respiration. 

4.  Very  high  atmospheric  temperatures. 

5.  Oiling  of  the  skin. 

The  following  measures,  while  they  cause  the  body  to  make  attempts  at 
decreased  heat  elimination,  do,  by  contact,  abstract  heat: — 

1.  Cold  baths,  enemata  and  water  drinking. 

2.  Contact  with  cold  air. 

Since  more  than  half  the  heat  taken  from  the  body  by  a  cold  bath  is  lost 
during  the  first  third  of  the  treatment,  short  cold  baths,  are  proportionately 
to  their  duration,  more  effective  than  long  cold  baths. 

The  activity  of  the  surface  circulation  being  the  essential  factor  in  the 
loss  of  heat  during  a  cold  bath,  it  follows  therefore  that  whatever  increases 
the  amount  of  blood  in  the  skin  and  the  rapidity  of  the  circulation  in  the  skin 
will  markedly  increase  heat  loss  during  a  cold  bath.  This  is  one  of  the  chief 
reasons  for  the  use  of  short  hot  applications  preparatory  to  the  use  of  the 
cold  bath. 


88  THE  HEAT  MECHANISM 

There  are  two  local  applications  of  cold  whose  chief  effect  upon  the  body 
temperature  is  not  by  the  abstraction  of  heat.  These  are  the  ice  cap  applied 
to  the  head  and  the  ice  bag  applied  over  the  heart.  Their  action  is  reflex. 
The  former  influences  heat  production  through  its  reflex  effect  upon  the 
thermogenic  centers  of  the  brain.  The  latter  reflexly  slows  the  heart  beat 
and  thereby  the  general  circulation,  which  in  turn,  decreases  heat  produc- 
tion. Of  course,  as  previously  stated,  these  effects  are  very  slight  in  health, 
but  of  inestimable  value  in  febrile  diseases. 

Heat  Regulation   (Thermotaxis) 

The  normal  temperature  of  the  body  is  maintained  by  the  nicety  of  the 
balance  between  heat  production  and  heat  elimination.  Increased  heat  pro- 
duction does  not  necessarily  mean  a  rise  of  body  temperature,  since  under 
normal  conditions,  the  heat  is  dissipated  as  rapidly  as  produced.  The  natural 
conditions  that  tend  to  increase  heat  production  usually  stimulate  the  elimi- 
nation of  heat  as  well,  and  so  a  balance  is  maintained.  For  example,  the 
body  is  exposed  to  a  draft  of  cold  air.  The  skin  assumes  a  goose-flesh  appear- 
ance by  contraction  of  the  involuntary  muscles;  it  is  pale  and  contains  less 
blood.  While  the  cold  air  abstracts  or  conducts  heat  from  the  body,  this 
lessened  circulation  in  the  skin  decreases  the  amount  of  heat  lost  from  the 
surface.  The  perspiratory  glands  are  less  active,  and  the  consequent  les- 
sened evaporation  of  water  from  the  skin  also  decreases  the  amount  of  heat 
eliminated.  At  the  same  time,  the  sensation  of  cold  influences  the  thermo- 
genic centers,  and  they  cause  the  tissues  to  produce  more  heat.  Even  the 
shivering  which  follows  the  exposure  to  cold,  being  muscular  action,  is  one 
method  of  producing  heat. 

Thus,  the  temperature  of  the  body  is  maintained  at  a  constant  point,  rather 
than  lowered  by  the  cold  atmosphere.  The  converse  is  true  of  a  short,  mod- 
erately warm  bath.  This  would  communicate  heat  to  the  body,  and  so  tend 
to  raise  the  temperature;  but  the  body  reacts  in  such  a  way  as  to  preserve 
the  balance.  The  skin  is  relaxed,  the  blood  vessels  dilated  and  the  perspira- 
tion increased,  so  that  more  heat  is  lost  by  dissipation  from  the  surface.  At 
the  same  time,  this  relaxing  effect  causes  loss  of  tone  in  the  tissue  generally, 
and  so  less  heat  is  produced.  These  results  are  due  to  the  control  exercised 
by  the  heat  regulating  centers  before  mentioned. 

It  must  not  be  supposed,  however,  that  heat  always  decreases  heat  pro- 
duction. Very  high  temperatures  markedly  increase  heat  production,  so 
much  so  that  fatal  poisoning  may  occur  in  such  conditions  as  heatstroke. 
Serious  cases  never  wholly  recover  from  the  effects  of  the  high  external 
temperature  and  the  internal  heat  produced  by  it.  They  are  ever  after 
extremely  susceptible  to  even  the  moderate  heat  of  tropical  climates  or 
direct  sunlight. 

While  an  agent  may  increase  both  heat  production  and  elimination  at  the 
same  time,  one  is  usually  increased  to  a  greater  extent  than  the  other.  For 
example,  a  cold  mitten  friction  at  first  abstracts  heat  from  the  body,  but 
the  reaction  causes  increase  heat  production,  as  shown  by  the  "warming 
effect. ' '  The  increased  circulation  of  the  skin,  which  is  part  of  the  reaction, 
causes  more  heat  to  be  lost.  The  total  effect,  however,  is  an  increase  of 


SUMMARY  89 

heat  in  the  body,  because  heat   production  is  stimulated   more   than  heat 
elimination. 

As  we  have  seen,  thermic  applications  produce  decided  changes  in  heat 
production  and  elimination.  However,  these  changes  do  not,  in  health,  pro- 
duce wide  alterations  in  the  body  temperature.  On  the  contrary,  the  same 
influences  applied  in  febrile  conditions  produce  decided  alterations. 

From  the  preceding  experiments,  it  will  be  seen  that  water  at  the  vary- 
ing temperatures  and  in  the  different  ways  in  which  it  may  be  applied  to  the 
body,  is  capable  ofiany  and  all  possible  variations  and  degrees  of  effect  upon 
the  heat  mechanism.  No  possible  alteration  of  heat  production  or  elimina- 
tion can  be  conceived  of,  that  water  is  not  capable  of  producing.  It  is  this 
versatility  of  application  and  effect  that  makes  hot  and  cold  water  of  so 
much  service  in  fever  and  disturbances  of  the  heat  mechanism. 

On  the  contrary,  drug  action  is  particularly  monotonous,  and  ideal  combi- 
nations impossible  to  make.  If  they  seem  to  act  in  a  rational  manner  upon 
one  part  of  the  mechanism,  it  will  be  found  that  they  have  an  adverse  act- 
ion upon  another  part.  And  usually,  this  adverse  action  more  than  outweighs 
any  good  which  may  be  accomplished.  This  will  be  considered  under  the 
subject,  "Fever  and  Antipyretic  Effects." 


PART    II 


THERAPEUTICS 


CHAPTER  XV 

THE  REALM  AND  LIMITATIONS  OF 

PHYSIOLOGIC  THERAPY 


Therapeutics  is  the  science  and  art  of  healing.  Disease  is  an  abnormal 
state  of  the  body  manifest  in  a  morbid  condition  of  structure  or  function. 
The  departure  from  the  normal,  nearly  always  begins  in  some  mild  way. 
Even  in  acute  diseases,  the  predisposition  is  laid  in  previous  unhygienic 
habits  or  surroundings.  There  are  two  general  types  of  disease  usually 
recognized,  viz.,  the  functional  and  the  organic.  In  the  former,  the  actual 
structure  of  the  diseased  organ  or  part  has  not  greatly  deviated  from  the 
normal.  The  condition  is  manifest  in  a  derangement  of  the  function  of  the 
part.  However,  even  in  many  so-called  functional  diseases,  it  is  possible, 
by  careful  microscopic  examination,  to  detect  more  or  less  of  pathologic  change. 
But  even  in  this  case,  the  alteration  in  structure  has  not  gone  on  to  such  an 
extent  as  to  preclude  the  possibility  of  a  restoration  to  normal  more  or  less 
complete. 

In  the  case  of  organic  disease,  such  gross  structural  changes  have  been  pro- 
duced as  to  be  readily  detected  and  of  such  a  character  as  to  preclude  the 
possibility  of  a  return  to  the  normal.  In  this  case,  physiologic  therapy  can 
accomplish  only  aleviation  of  the  symptoms  and  such  building  up  of  the 
general  vitality  and  resistance  of  the  patient  as  to  more  or  less  counterbal- 
ance the  effects  of  the  structual  lesion.  In  many  cases  where  no  indispens- 
able part  is  involved,  radical  means  may  be  used,  such  as  the  removal  of  a 
malignant  neoplasm,  or  some  operation  may  be  done  to  overbalance  or  palli- 
ate the  results  of  the  disease,  as  in  the  case  of  Talma's  operation  for  hepatic 
cirrhosis,  or  Edobohl's  operation  for  renal  insufficiency.  Purely  functional 
diseases  are,  however,  nearly  always  best  treated  by  physiologic  means. 

In  the  course  of  many  diseases  a  point  is  reached  beyond  which  a  return 
to  the  normal  is  impossible  without  the  intervention  of  some  radical  proced- 
ure. This  is  especially  the  case  in  inflammations.  In  certain  grades,  stages 
and  types  of  inflammation,  it  is  entirely  possible,  by  natural  means,  to  aid  or 
affect  the  return  to  normal  structure  without  the  intervention  of  radical 
measures.  This  is  true  of  such  an  inflammation  as  dry  or  serous  pleurisy, 
pneumonia  or  a  simple  surface  infection,  but  where  these  inflammations  have 
gone  on  to  the  formation  of  a  suppurative  focus  or  an  abscess,  physiologic 
means  alone  are  unable  to  accomplish  the  full  return  to  the  normal  condition. 
True,  in  time,  the  abscess  might  work  its  way  to  the  surface,  and  so  evacu- 
ate, but  in  most  cases,  it  is  a  long,  tedious  process  and  the  patient  is  very 
much  reduced  in  vitality  by  such  delay,  which  delay  in  many  cases,  may 


94  REALM  OF  PHYSIOLOGIC  THERAPY 

prove  fatal  from  the  absorption  of  toxic  products.  It  is  necessary,  by  some 
radical  means,  to  accomplish  the  speedy  evacuation  of  the  pus  and  free 
drainage  of  the  abscess  cavity.  The  old  dictum,  ubi  pus,  ibi  evacua,  is  just 
as  true  now  as  when  it  was  first  enunciated.  Translated  into  terms  of 
activity,  it  means,  where  there  is  pus,  provide  an  outlet.  It  is  necessary 
that  evacuation  be  provided  for.  This,  nature  itself  seeks  to  accomplish; 
but  unaided,  its  attempts  are  accompanied  by  great  destruction  of  tissue 
and  much  delay.  By  vigorous  treatment,  systematically  applied,  it  is  often 
possible  to  obviate  the  necessity  for  radical  interference.  But  when  the 
stage  of  suppuration  has  been  reached  or  is  imminent,  surgical  intervention 
is  just  as  much  an  assistant  to  nature  as  physiologic  means  and  therefore 
just  as  rational. 

The  same  principles  apply  to  the  use  of  vaccines  and  antitoxines.  If  the 
body  has  sufficient  reserve  power  and  the  infection  does  not  progress  too 
rapidly,  the  system  may  provide  adequate  means  of  cure.  Yet  the  course 
of  certain  infections  teaches  us  that  such  circumstances  can  not  always  be 
relied  upon.  Where  available  and  of  demonstrated  value  no  one  would 
think  of  omiting  the  use  of  serum  therapy.  Nor  when  this  is  used  should 
physiologic  means  be  left  out  simply  because  other  procedures  are  more 
essential  in  a  given  case.  All  measures  of  value  should  be  used  in  order  to 
still  further  assist  the  body  in  combating  the  infection. 

We  may  then,  in  general,  say  that  where  physiologic  means  are  unable  to 
aid  the  organism  in  re-establishing  the  normal  structure  and  function,  radical 
interference  is  necessary.  This  division  line  can  best  be  determined  by  care- 
ful consideration  of  experience  in  the  light  of  the  usual  trend  of  the  particu- 
lar disease  in  question.  Experience  has  shown  that  a  certain  type  of  inflam- 
mation in  one  organ  or  location  may  tend  to  a  serious  issue,  such  as  abscess  or 
gangrene,  while  in  another  organ  or  location,  it  usually  tends  to  resolution. 
For  example,  we  may  cite  the  case  of  appendicitis  on  the  one  hand  and  of 
salpingitis  on  the  other.  In  both  cases,  physiologic  means  may  accomplish 
a  return  to  the  normal,  but  in  the  case  of  appendicitis,  this  return  is  not  to 
be  relied  upon  for  permanent  cure.  The  tendency  is  to  recurrence  and  even, 
in  a  single  attack,  to  perforation  and  peritonitis;  while  with  the  pelvic 
inflammation,  physiologic  means  produce  a  return  to  the  normal  which  can 
better  be  relied  upon  to'  permanently  restore  to  the  normal  with  a  safe  issue; 
and  under  proper  physiologic  treatment,  if  taken  early,  there  is  little,  or  at 
least  less,  tendency  to  rupture  or  abscess  formation.  Even  in  the  case  of 
formation  of  pus  in  the  tube,  it  is  best  to  delay  surgical  interference  until 
the  acute  inflammation  has  subsided  and,  if  possible,  the  temperature  has 
returned  to  normal.  At  best,  it  is  dangerous  and  conducive  to  spread  of 
infection,  if  salpingectomy  be  done  during  the  continuance  of  the  acute 
inflammation. 

It  is  quite  otherwise  with  appendicitis.  Not  only  does  operation  in  the 
acute  stage  give  good  results,  but  because  of  the  inability  to  determine  the 
immediate  issue,  it  is  imperative  to  interfere  as  soon  as  possible.  True,  a 
patient  may  go  through  a  number  of  acute  attacks,  all  of  which  subside 
without  serious  complications,  but  this  can  not  be  relied  upon  to  continue. 
In  each  succeeding  attack  there  is  greater  liability  to  perforation. 

Considering  all,  we  may,  then,  draw  the  conclusion  that  rational  therapy 


ESSENTIALS  OF  THERAPY  95 

is  based  upon  three  things, —experiment,  experience  and  judgment,— the 
latter  for  the  purpose  of  applying  to  the  individual  case  the  general  laws 
and  deductions  relative  to  that  condition.  It  requires  an  extreme  nicety  and 
perfect  balance  of  judgment  to  determine  whether  a  given  border  line  case 
should  be  treated  by  physiologic  or  radical  therapy.  This  faculty  has  been 
termed  "surgical  judgment."  But  its  application  requires  more  than  a 
knowledge  of  operative  technique.  The  surgeon  who  is  pre-eminently  a  phy- 
sician and  whose  armementarium  is  well  stocked  with  physiologic  means,  will 
meet  with  the  best  success.  Let  not  the  surgeon  be  over  enthusiastic  about 
operative  treatment  nor  the  physician  so  confident  of  natural  means  as  to 
procrastinate  when  prompt  surgical  interference  offers  the  best  hope  of 
speedy  and  permanent  recovery. 

Basic  Principles  of  Therapy 

The   philosophy   of   the  practice  of  therapeutics  is  summed  up  in  three 
things.    The  proper  application  of  these  may  be  considered  rational  medicine. 
First,  removal  of  the  cause. 
Second,  treatment  of  the  existing  condition. 

Third,  relief  of  such  symptoms  as,  by  their  severity,  in  turn  become 
causes. 

After  removal  of  the  cause  many  functional  diseases  right  themselves 
(sublata  causa,  tollitur  effectus)  l  without  further  treatment,  since  perverted 
habits  of  function  have  not  become  fixed.  In  the  large  majority  of  cases 
in  addition  to  removal  of  the  cause,  it  is  necessary  to  direct  attention  to  the 
existing  perversions  of  function  and  structure.  Usually,  the  measures  found 
most  successful  in  the  treatment  of  a  disease  meet  all  three  of  these  indica- 
tions. It  is,  therefore,  seldom  necessary  to  consider  them  separately.  For 
example,  in  typhoid  fever,  the  cold  bath  increases  phagocytosis,  thus  com- 
bating the  cause — infection;  it  relieves  internal  congestion,  increases  the 
oxidation  and  elimination  of  toxines;  it  relieves  the  nervous  symptoms  and 
lessens  the  fever.  A  single  procedure  meets  all  three  indications. 

1    When  the  cause  is  removed,  the  effect  disappears. 


CHAPTER    XVI 
FEVER  AND  ANTIPYRETIC  EFFECTS 


Fever  is  a  disturbance  of  the  heat  mechanism  in  which  there  is  a  more  or 
less  prolonged  rise  of  temperature  above  the  normal.  The  principal  cause 
is  the  circulation  of  unusual  toxic  substances  in  the  blood.  It  is  the  result 
of  a  protective  effort,  an  attempt  on  the  part  of  the  body  to  cope  with  these 
poisons;  but  the  organism  may  be  overwhelmed  by  them  and  so  be  unable  to 
oxidize  them  with  sufficient  rapidity  to  protect  the  body.  Or,  because  of 
the  nature  of  these  poisons,  the  heat  regulating  centers  and  the  vasomotor 
centers  are  disturbed  and  the  balance  unsettled.  If  heat  elimination  were 
to  keep  pace  with  the  heat  production,  even  though  the  latter  were  greatly 
increased,  there  could  be  no  rise  of  temperature.  Many  toxines  cause  a 
sensation  of  chilliness  and  thus  decrease  the  heat  loss,  and  fever  results. 
While  the  body  attempts  to  protect  itself,  its  efforts  are  not  always  well 
directed  or  governed. 

The  poisons  producing  pyrexia  are  of  various  origin.  They  may  be  formed 
in  the  body  or  introduced  from  without.  In  the  former  case  the  toxemia 
may  be  due  to  the  accumulation  of  body  poisons,  i.  e.,  those  which  are 
normally  produced  in  health  by  ordinary  metabolism,  but  are  usually  elimin- 
ated as  fast  as  formed.  These  poisons  are  called  leucomaines.  They  do 
not  produce  the  higher  types  of  fever,  nor  fever  of  long  duration.  The 
poisons  due  to  anger,  worry  and  other  nervous  disturbances  are  classed  under 
this  head,  although  they  are  not  normal  to  the  body. 

Prominent  among  the  leucomaines,  as  a  cause  of  fever,  are  the  purin  bases. 
Apropos  of  this  subject  we  quote  the  following  from  Lusk: —  J 

"However,  there  is  a  very  noteworthy  record  made  by  A.  R.  Mandel  that 
the  rise  of  temperature  in  aseptic  or  surgical  fevers  is  accompanied  by  a 
large  increase  in  the  purin  bases  in  the  urine  of  patients  fed  with  milk. 
The  temperature  rises  and  falls  with  the  quantity  of  purin  bases  eliminated. 
The  uric  acid  elimination  is  reduced. 

'  'That  the  purin  bases  can  be  the  cause  of  the  rise  of  temperature  is  indi- 
cated by  the  experiments  of  Burian  and  Schur  who  found  that  when  nucleo- 
proteid  was  administered  intravenously  to  a  dog,  a  rise  of  temperature  fol- 
lowed. Mandel  showed  that  a  subcutaneous  injection  of  40  milligrams  of 
xanthin  caused  a  marked  rise  in  the  temperature  of  a  monkey,  and  that  the 
administration  of  a  strong  decoction  of  60  grams  of  coffee  (containing  tri- 
methyl-xanthin)  to  a  man  unused  to  coffee  drinking,  was  followed  by  a 
febrile  temperature." 

Toxines  may  be  produced  by  saprophytic  bacteria  (those  of  decomposition) , 

1     Science  of  Nutrition,  1906.  p.  267. 


CAUSES  OF  FEVER  97 

growing  in  the  body  or  in  the  alimentary  tract.  These  conditions  are  known 
as  sapremia  and  auto-intoxication.  Foods  decomposed  by  bacterial  action 
may  serve  as  the  source  of  poison,  as  in  the  eating  of  decomposed  meat, 
cheese,  etc.  Such  products  of  bacterial  decomposition  are  known  as  pto- 
maines. Bacterial  toxines  produced  by  pathogenic  bacteria,  growing  within 
the  body  itself,  are  the  most  usual  causes  of  fever  and  those  with  which  we 
are  most  concerned  in  the  treatment  of  this  condition. 

Ultimate  Causes  of  Pyrexia.  The  following  outline  is  modified  and  abridged 
from  Sollmann.  2 

Fever  may  be  due  to, — 

1.  Exposure  to  excessive  external  heat,  as  in  sunstroke.     Also  internal 
heat  (over-oxidation)  as  in  excessive  muscular  exercise. 

2.  Certain  drugs,  such  as  the  convulsants,  cocaine  and  strychnin,  by  the 
production  of  convulsions  or  spasm  of  the  muscles. 

3.  Toxic  Proteins. 

a.  Bacterial  toxines  of  infectious  diseases. 

b.  Ptomaines. 

c.  Auto-intoxication  (intestinal,  biliary,  urinary,  etc.). 

d.  Absorption  of  unconverted   digestive    products,  as  albiimoses  and 
peptones  in  a  diet  too  rich  in  proteid;  or  due  to  digestive  disorders. 

Manifestations  of  Fever.  In  addition  to  the  causes  of  fever,  it  is  necessary 
to  consider  the  symptoms,  since  these  are  an  indication  of  the  real  condition 
of  the  patient  and  may  be  of  such  a  magnitude  as  to,  in  turn,  become  a 
cause  of  additional  trouble;  in  which  case,  special  treatment  must  be  directed 
toward  their  relief  or  palliation. 

The  toxines,  or  the  high  temperature,  cause  the  following  symptoms, 
recognized  as  characteristic  of  fevers: — 

1.  Nervous  disturbances,  such  as  malaise,  headache,  backache,  insomnia, 
delirium,  etc. 

2.  Hot  dry  skin,  or  cold  clammy  skin. 

3.  Increased  pulse  rate  and  blood  tension. 

4.  Increased  rate  of  respiration. 

5.  Excessive  thirst. 

6.  Loss  of  appetite,  foul  breath,  coated  tongue. 

7.  Constipation. 

8.  Urine  scanty,  highly  colored,  high  specific  gravity,  increase  of  urea. 

Principles  of  Antipyresis 

Since  the  body  by  increased  oxidation  attempts  to  get  rid  of  toxines,  this 
burning  is  to  be  encouraged  rather  that  hindered.  The  fever  should  be  con- 
trolled, not  combated.  The  system  is  to  be  aided  in  its  attempt  to  oxidize 
and  eliminate  the  poisons.  The  idea  that  the  reduction  of  temperature  is 
the  sole  object  in  the  treatment  of  fevers  has  become  so  firmly  fixed  in  the 
minds  of  physicans  and  .laymen  that  it  is  hard  to  eradicate.  It  was  this  idea 
that  led  to  the  use  of  the  medicinal  antipyretics,  the  giving  of  which  is  not 
only  wholly  irrational,  but  productive  of  very  serious  complications  and 

2    Text  Book  of  Pharmacology,  1901,  p.  394. 


98  FEVER  AND  ANTIPYRETIC  EFFECTS 

sequellae.  To  a  great  extent,  the  same  idea  also  prevails  with  regard  to  the 
use  of  the  cold  bath  in  fever,  much  to  the  discredit  of  hydrotherapy  and 
rational  therapeutics.  Many,  too,  regard  the  reduction  of  fever  as  the  only 
asset  of  hydrotherapy,  and  fever  as  the  only  condition  in  which  hydriatic 
measures  are  applicable.  That  both  ideas  are  erroneous  has  already  been 
shown  and  will  be  made  plainer  as  we  consider  the  rationale  and  results  of 
hydrotherapy,  not  only  in  fever,  but  in  a  host  of  other  maladies. 

The  basic  object  in  the  treatment  of  fevers  is  the  same  as  in  all  other 
diseases,  viz.,  the  removal  of  the  cause.  This  can  be  accomplished  only  by 
decreasing  the  toxemia.  In  only  a  few  febrile  diseases  has  medical  science 
discovered  a  direct  antitoxine  or  perfected  a  workable  system  of  producing 
immunity.  We  are,  therefore,  under  the  necessity  of  directing  our  efforts 
toward  increasing  the  oxidation  and  hastening  the  elimination  of  these  bac- 
terial toxines;  increasing  phagocytosis;  and  assisting  and  conserving  the 
powers  of  the  tissues  in  the  production  of  antitoxines,  antibodies,  opsonin, 
etc.,  this  latter  action  being  largely  the  work  of  the  phagocytes  themselves, 
upon  the  integrity  and  activity  of  which  immunity  depends  (Metchnikoff). 

In  addition  to  this  basic  object — the  removal  of  the  cause — it  is  necessary 
to  prevent  the  over  accumulation  of  heat,  a  thing  which  is  accomplished  by 
the  same  means.  And  third,  to  mitigate  the  symptoms,  especially  those 
referable  to  the  nervous  system.  Combat  headache,  malaise,  insomnia, 
delirium,  etc.  This  also  is  done  by  the  cold  bath  and  other  cold  applications. 
In  fact,  all  of  these  results  can  be  and  are  obtained  by  properly  applied 
hydriatic  measures  as  has  been  demonstrated  by  the  experiments  cited  in 
the  previous  part  of  this  work. 

Further  in  regard  to  the  connection  of  the  circulatory  system  with  the 
general  manifestations  of  fever  and  especially  with  regard  to  the  circulatory 
complications  which  contribute  so  largely  to  the  mortality,  experimental 
pathology  has  laid  a  very  firm  foundation  for  the  use  of  hydrotherapy  in 
fevers  of  infectious  origin.  The  researches  of  Romberg  and  Passler  are 
considered  the  basis  of  our  knowledge  of  the  state  of  the  heart  and  blood 
vessels  in  these  diseases.  The  reports  of  their  work  3  have  shown  conclus- 
ively that  circulatory  failure  is  not  primarily  due  to  the  heart  itself,  but  to 
paralysis  of  the  blood  vessels  brought  about  by  damage  to  the  vasomotor 
centers.  In  this  connection  we  can  not  do  better  than  quote  from  the  brief 
resume  of  these  researches  given  by  Janeway  and  from  remarks  made  by 
Forchheimer.  4 

"They  studied  the  fatal  collapse  which  occurred  in  rabbits  after  infection 
with  the  pneumococcus,  the  bacillus  pyocyaneus,  and  the  diphtheria  bacillus; 
the  first  producing  a  true  septicaemia,  the  latter  a  local  lesion  with  general 
toxaemia.  All  of  the  250  animals  used  were  autopsied,  and  the  heart  and 
other  important  organs  examined  microscopically.  Their  method  consisted 
in  observing  the  mean  carotid  pressure  at  different  stages  of  the  disease, 
and  the  effect  upon  it  of  (1)  abdominal  massage,  which  increased  the  work 
of  the  heart  by  supplying  it  with  more  blood;  (2)  compression  of  the  aorta 

3  Romberg    and    Passler— Deutsch.   Archiv.   fur    klin.    Med.,  1895,    LXIV  pp.  652-763:   also 
Passler— Munchen.  Med.  Wochenschrift,  1901  XLVIII,  No.  8 

4  The   Clinical   Study  of   Blood  Pressure,  pp.  155,  156;    and  Cardiac  and  Vascular  Complica- 
tions in  Pneumonia — Journal  of  American  Medical  Association,  Oct.  30,  1909,  p.  1450. 


TOXIC  VASOMOTOR-PARALYSIS  99 

above  the  diaphragm,  which  makes  the  work  of  the  heart  maximal;  (3)  irri- 
tation of  the  nasal  mucous  membrane  with  a  Faradic  current,  which  causes 
extreme  reflex  vasoconstriction;  and  (4)  short  asphyxia  (30  sees.),  which 
acts  similarly,  only  on  both  medullary  and  spinal  vasomotor  centers;  while 
sensory  stimulation  affects  only  the  center  in  the  medulla.  They  reasoned 
that,  should  there  be  no  rise  in  pressure  from  sensory  irritation  or  suffoca- 
tion, while  abdominal  massage  and  ligature  of  the  aorta  still  called  forth  a 
well  marked  one,  then  the  heart  must  be  functionally  capable  and  the  vaso- 
motor mechanism  paralyzed.  To  determine  whether  the  central  or  peripheral 
vasomotor  mechanism  was  at  fault,  they  used  injections  of  barium  chloride, 
which  cause  constriction  of  the  arteries  by  purely  local  action  upon  them. 

"Their  experiments  showed  that  the  blood  pressure  and  the  response  to 
all  the  procedures  remained  perfectly  normal  throughout  the  early  stage  of  the 
disease,  being  unaffected  by  the  fever.  The  greatest  elevation  of  pressure 
was  obtained  on  stimulating  the  mucous  membrane  of  the  nose.  When  the 
animals  showed  signs  of  impending  collapse  in  their  behavior,  the  blood 
pressure,  though  still  normal,  began  to  sink,  while  the  heart  beat  more 
forcibly.  Hand  in  hand  with  this  went  a  great  reduction  in  the  rise  of  pres- 
sure from  sensory  irritation,  a  moderate  decrease  in  the  asphyxial  elevation, 
but  as  high  a  pressure  as  before  after  abdominal  massage.  In  many  cases 
the  pressure  did  not  fall  until  the  reflex  rise  had  been  almost  abolished, 
evidently  being  maintained  by  increased  cardiac  energy,  in  spite  of  the 
vascular  dilatation.  Finally,  in  complete  collapse,  which  developed  very 
rapidily,  the  aortic  pressure  fell  to  the  lowest  level,  as  after  destruction  of 
the  spinal  cord;  no  reflex  rise  could  be  obtained,  but  abdominal  massage 
gave  an  immediate  elevation.  It  was  evident,  therefore,  that  the  circulatory 
disturbance  at  the  height  of  the  infection  depended  absolutely  upon  a  par- 
alysis of  the  vessels,  not  upon  any  damage  to  the  force  of  the  heart. 

"As  regards  their  reaction  to  compression  of  the  thoracic  aorta,  the  diph- 
theria animals  showed  a  divergence  from  the  pneumococcus  ones;  the  latter 
evincing  practically  normal  cardiac  reserve  force,  while  the  former  showed 
a  distinct  falling  off.  Anatomically,  also,  the  diphtheria  hearts  had  suffered 
damage,  parenchymatous  degeneration  being  well  marked,  as  in  clinical 
diphtheria.  The  pneumococcus  animals  had  scarcely  any  change  in  their  car- 
diac muscle.  Thus  evidence  of  weak  ness  in  the  heart  muscle  in  diphtheria  was 
of  minor  importance,  the  real  cause  of  death  in  all  cases  being  the  complete 
loss  of  vasomotor  tone.  By  intervenous  injections  of  barium  chloride  they 
proved  decisively  that  this  was  due  to  central  paralysis.  Their  conclusions 
were,  that  all  three  organisms  used  damage  the  circulation  through  paralyz- 
ing the  vasomotor  centers  throughout  the  medulla  and  cord;  this  vasomotor 
paralysis  leads  to  a  fall  in  blood  pressure,  and  further,  to  a  changed  blood 
distribution;  the  splanchnic  circulation  is  overfilled,  the  brain,  muscle  and 
skin  vessels  are  empty;  the  heart  is  not  affected,  except  secondarily  through 
insufficient  blood  supply." 

Forchheimer's  discussion  on  this  latter  condition— splanchnic  conges 
as  follows:     "Long  ago  it  has  been  shown  in  animals,  that  on  section  of  the 
splanchnic  nerve,  an  enormous  quantity  of  blood  accumulates  in  the  intes- 
tine, which  is  followed  by  intense  anemia  in  other  organs,  especially  11 
central  nervous  system,  which  may  cause  death.     The  splanchnic  nerve  u 


100  FEVER  AND  ANTIPYRETIC  EFFECTS 

vasomotor  nerve  of  the  intestines,  and  its  section  causes  paralysis  of  vaso- 
motor  function  and  enormous  dilatation  of  the  blood  vessels.  In  paralyzing 
the  vasomotor  center  with  the  pneumococcus  the  same  result  follows  in  man. 
In  brief,  in  man  there  is  first,  dilatation  of  blood  vessels  in  the  splanchnic 
area;  the  blood  pressure,  which  sooner  or  later  is  normally  low  in  pneumonia, 
sinks;  the  heart,  which  is  supplied  by  an  insufficient  quantity  of  blood,  which 
is  gradually  becoming  stationary  in  the  affected  area,  continues  to  draw  blood 
from  other  places,  the  liver,  the  skin,  the  muscles  and  central  nervous 
system,  and  becomes  more  and  more  rapid  and  ineffectual,  'bleeding  itself 
into  the  splanchnic  area,'  and  finally  stops.  The  intracardiac  pressure  is 
reduced  so  that  the  myocardium  ceases  to  contract;  moreover,  the  various 
cardiac  and  vasomotor  centers  become  asphyxiated,  and  therefore  paralyzed. " 

These  above  quoted  facts  and  discussion  very  clearly  show  the  rationale  of 
hydrotherapy  in  infectious  diseases.  The  vasomotor  stimulation  which 
results  from  hydriatic  procedures  amply  meets  the  needs  of  the  situation, 
which  need  it  is  impossible  to  meet  by  medicinal  therapy  of  any  sort. 

The  Effects  of  Medicinal  Antipyretics 

1.  Drugs  having  a  collapse  action,  such  as  aconite  and  viratrum  viride. 
These    lessen    the  force  of  the  heart  beat  and  dilate  the  blood  vessels,  so 
lowering  the  blood  pressure.     Heat  production  is  decreased,  because  of  this 
latter  action.     Vasodilatation  favors  the  loss  of  heat  from  the  skin.     This 
is  not  a  tonic,  but  an  atonic  dilatation  and  so,  in  no  way,  restores  the  lost 
tone  to  the  circulatory    system.      Both  these  drugs  decrease  fever  at  the 
expense  of  the  heart's  action  and  so  prove  dangerous  in  asthenic  fevers,  or 
where  there  is  cardiac  weakness,  dilatation  or  incompetency  already  existing. 

2.  Alcohol.     The  only  beneficial  (?)  action  of  alcohol,    as  relied  upon  in 
fever  and  as  given  in  so-called  therapeutic  doses,  is  upon  the  smaller  blood 
vessels,    in  which  it  causes  an  atonic  or  paretic  dilatation  and  consequent 
loss  of  heat  from  the  skin.     At  the  same  time,  it  dilates  the  visceral  capil- 
laries which  are  already  congested  in  febrile  conditions.     Their  paretic  condi- 
tion renders  the  viscera  much  more  liable  to  suffer  from  retrostasis  when 
the  body  is  exposed  to  cold.      Alcohol   decreases   metabolic    processes  and 
oxidation. :i    The  tissues    are  less  active  so  that  toxines,    instead  of  being 
more  rapidily  oxidized  and  eliminated,    tend  to  accumulate  in  the  system. 
Alcohol  lessens  the  phagocytic  activity, —  the  natural  defense  against  infec- 
tion, and  discharges  immunity.     Delearde  has  shown  that  the  absorption  of 
alcohol  is  a  grave  obstacle  to  immunization  against  hydrophobia.     Abbot, 
in  experimenting  on  animals,  proved  that  those  subjected  to  the  influence 
of  alcohol  were  more  susceptible  to  the  harmful    effects  of  streptoccocci, 
bacillus  coli  and  other  bacteria.     Both  Delearde  and  Laitinen  found  it  impos- 
sible to  vaccinate  against  anthrax,  animals  that  had  been  given  alcohol  on 
several  successive  days. 

3  "Alcohol  in  excessive  doses  and  prolonged  anaesthesia  both  paralyze  the  heat-regulating 
mechanism.  A  man  who  is  'dead  drunk'  resembles  a  cold  blooded  animal;  exposure  to  cold  pro- 
duces not  an  increase  but  a  decrease  in  combustion,  and  his  temperature  steudily  falls.  It  is 
not  surprising,  therefore,  that  death  from  exposure  chiefly  occurs  in  the  case  of  intoxicated 
persons."  (Hutchison — Applied  Physiology,  1908,  p.  67.) 


MEDICINAL  ANTIPYRETICS  m 

3.  The  Coal  Tar  Products,    as  Acetanilid,    Phenacetin  and  Antipyrin 
These  decrease  heat  production  by  the  direct  toxic  action  of  their  aromatic 
radicles  on  the  heat  centers  in  the  brain  and  on  the  processes  of  oxidation 
and  proteid  metabolism. "    This  is  shown  by  the  decrease  in  tissue  destruc- 
tion, lessening  of  urea,  etc.     This  effect  is  most  marked  in  fever,  where  the 
rational  procedure  is  to  increase  the  burning  up  of  poisons,    (purins,  toxal- 
bumens,  bacterial  toxines,  etc.)    in  order  to  get  rid  of  them.     Neither  do 
these  drugs   increase  the  elimination  of  poisons.     They  are  very  powerful 
cardiac   depressants  and   possess  a  decided   collapse   action.     This  is  most 
marked  with  acetanilid.     They  cause  breaking  up  of  the  red  cells  with  the 
formation  of  methemoglobin,  thus  in  a  second  way,  preventing  oxidation  by 
limiting  the  oxygen  carrying  capacity  of  the  blood.     The  movements  of  the 
whites  are  arrested.     Phagocytosis  is  prevented.     This  is  another  example 
of  drugs  that  render  the  body  less  able  to  resist  infection. 

4.  Quinin.     This  drug  lowers  temperature  by  decreasing  heat  production. 
Its  action  is  said  to  be  chiefly  peripheral  upon  the  thermogenic  tissues,  in 
decreasing  nitrogenous  metabolism.     This  decrease  may  reach  as  high  as  39 
per  cent,  with  large  doses.  5   The  drug  probably  owes  its  toxicity  to  its  aro- 
matic nucleus,  the  same  as  the  coal  tar  products.     It  not  only  hinders  the 
destruction  of  nitrogenous  toxines,  but  is  a  powerful  poison  to  the  phagocy- 
tes, arresting  their  movements    immediately  on  contact  with  them.     This 
result  obtains  when  only  0.5  to  1  part  in  1000  of  solution  is  used.     A  some- 
what larger  dose  causes  their  destruction  (Binz,  Sollmann).     According  to 
recent  experiments  by  Manwaring  and  Ruh,  larger  amounts  than  0.008  per 
cent  of  quinin  causes  complete  suppression  of  phagocytosis.     Since  1-13  of 
the    body  weight  is  blood,  an  individual  weighing  130  pounds  possesses  10 
pounds  of  blood,  totalling  70,000  grains.    If,  at  any  one  time,  there  should 
be  in  the  blood  of  a  person  of  this  weight,  ten  grains  of  quinin,  there  would 
then  be  acting  upon  the  phagocytes  an  amount  nearly  double  the  minimum 
toxic  dose.     Quinin  frequently  causes  hemoglobinuria.     Metchnikoff 6  makes 
the  following  statement:  "It  is  not  only  opium  and  alcohol  which  hinder  the 
phagocytic  action.     A  number  of  other  substances    regularly    employed  in 
medicine,  cause  the  same  results.    Even  quinin,  the    .    .     .     effect  of  which 
in  malarial  fevers  is  indisputable,  is  a  poison    for   the   white   blood  cells. 
One  should,  therefore,  as  a  general  rule,  avoid  as  far  as  possible  the  use  of 
all  sorts  of  medicaments,    and    limit   one's  self  to  the  hygienic    measures 
which  may  check  the  outbreak  of  infectious  disease.     This  postulate  further 
strengthens  the  thesis  that  the  future  of  medicine  rests  far  more  in  hygiene 
than   therapeutics." 

5.  Diaphoretics,  as  Pilocarpin  and  Dover's  Powder.     These  lower  febrile 
temperature  by  producing  sweating.      This  in  itself,  is  not  irrational.     In 
the  case  of  the  former,  it  has  recently  been  shown  that  this  is  at  the  expense 
of  the  heart's  astion.     The  latter  drug  contains  opium  which  has  the  same 
action  on  the  phagocytes  as  alcohol,  quinin  and  coal  tar  products. 

6.  Refrigerants,  such  as  the  alkaline  citrates,  organic  acids  and  acid  organic 

4  White  and  Wilcox-Materia  Medica  and  Therapeutics,  1900,  p.  300;  also  Sollmann— Text  Book 
of  Pharmacology,  1901,  p.  355. 

5  Sollmann— Ibid.,  p.  346.    See  also  Adami— Inflammation,  1907,  p.  152. 

6  New  Hygiene,  p.  28. 


102  FEVER  AND  ANTIPYRETIC  EFFECTS 

salts.  The  alkalescence  of  the  blood  is  diminished  in  auto-intoxication  and 
infectious  diseases.  Bouchard  failed  to  neutralize  the  excess  of  acid  in  the 
blood  by  the  administration  of  inorganic  alkalies.  The  citrates,  tartrates, 
etc.,  do,  however,  favor  kidney  activity  (diuresis)  and  sweating  (diaphore- 
sis) and  so  aid  in  the  elimination  of  toxines.  Experience  demonstrates  that 
the  natural  fruit  juices,  containing  these  acids  and  their  salts,  give  better 
results  in  these  respects  than  artificial  preparations  and  do  possess  a  true 
refrigerant  action. 

No  great  discernment  is  necessary  to  decide  that  antipyretic  drugs  are 
harmful  in  fever.  The  majority  of  fevers  are  due  to  infections,  i.  e.,  are 
bacterial  toxemias.  These  drugs  in  no  way  remove  the  cause,  nor  do  they 
assist  the  body  to  overcome  the  infection.  On  the  contrary,  they  destroy 
or  cripple  the  agents  of  natural  defense— the  leucocytes,  rendering  them 
an  easy  prey  to  bacteria. 

Rationale  of  Hydrotherapy  in  Febrile  Disease 

The  principal  object  to  be  sought  in  the  treatment  of  fever  is  the  com- 
bating of  the  infection.  The  antiseptic  treatment  of  infections  has  proven 
a  failure.  There  are  no  germicides  known  which  have  given  anything  like 
even  moderate  success  in  dealing  with  bacteria.  A  few  like  hexamethy- 
lenamin  are  valuable  aids,  but  of  limited  range.  The  chemical  destruction 
of  bacteria  within  the  human  organism  is  a  disappointment  and,  as  remarked 
by  one,  "we  aim  at  the  germs  and  hit  the  patient."  The  organism  is  hind- 
ered more  than  it  is  helped. 

The  body  itself,  must  be  aroused  to  combat  the  infection.  This  is  most 
effectually  accomplished  by  those  means  which  increase  the  vital  resistance 
of  the  body,  conserving  its  power,  and  especially  those  means  which  increase 
the  number  and  efficiency  of  the  phagocytes.  It  has  already  been  shown 
how  this  may  be  accomplished.  It  will  also  be  noted  that  cold  applications 
as  suited  to  the  varying  needs  of  different  diseases,  compass  all  these  results. 
We  have  seen  that  cold  produces  a  leucocytosis,  restores  the  diminished 
alkalinity  of  the  blood,  produces  an  active  arterial  hyperemia,  increases  and 
sustains  blood  pressure,  so  that  life  giving,  energizing  blood  circulates  more 
rapidily  where  previously  there  was  stasis,  venous  hyperemia,  leucopenia, 
lowered  alkalinity,  and  a  blood  laden  with  leucomaines,  toxins  and  acid 
poisons.  The  elimination  of  toxic  products  of  bacterial  life  is  hastened  and 
their  oxidation  increased  by  cold.  The  phagocytes  and  body  tissues  are  so 
energized  that  the  histogenous  production  of  antitoxines,  antibodies,  opsonin, 
etc.,  is  increased.  While  all  these  changes  are  being  brought  about,  the 
lessened  toxicity  of  the  body  fluids  relieves  the  nervous  system  and  it  is 
quieted  and  invigorated  by  the  tonic  influence  of  the  cold.  Restlessness, 
insomnia  or  delirium  gives  way  to  clear,  co-ordinated  action  or  undisturbed 
sleep.  The  hot,  dry  skin  or  the  cold,  clammy  skin  is  replaced  by  the  warm 
moist  surface.  This  remarkable  group  of  changes,  all  of  which  are  bene- 
ficial, and  derived  form  a  single  agent — cold  water— it  is  impossible  to  bring 
about  by  any  other  known  therapeutic  agent  or  combination  of  agents.  It  is 
simply  unique  in  the  realm  of  therapy. 

Let  us  now  turn  our  attention  to  the  differences  in  the  effects  of  the  vari- 


HYDRIATIC  ANTIPYRETICS  m 

ous  thermic   applications  used  in  the  treatment  of  fevers.    The  following 
classification  will  be  found  helpful:— 

1.  Applications  of  cold. 

(a)  Prolonged— direct   antipyretic,    by  abstracting  more  heat  than  is 
produced. 

(b)  Short— stimulate  heat  production  as  much  or  more  than  they  increase 
heat  elimination 

2.  Applications  of  heat. 

(a)  Prolonged— antipyretic  by  increasing  heat  elimination  through  pro- 
fuse sweating. 

(b)  Short— an  adjuvant,  prepares  the  body  for  cold  applications. 

The  physiologic  effects  of  the  four  classes  may  be  studied  under  the  two 
following  heads: — 

1.  Effect  on  heat  production. 

2.  Effect  on  heat  elimination. 

Prolonged  Cold.    The  Brand  bath  may  be  taken  as  a  type  of  this  class  of 
hydriatic  antipyretics,  the  effects  of  which  are  as  follows:— 

1.  Heat  production  is  decidedly  increased.      This  is  due  to  the  thermic 
stimulus  arising  from  contact  with  the  cold  water.     Oxidation  and  nitrogen- 
ous metabolism  are  both  increased.      There  is  not  only  an  increase  in  the 
oxidation  and  consequent  destruction  of  poisons,  but  their  elimination  in  an 
incompletely   oxidized    state    is   hastened.      This  is  proven  by  the  decided 
increase  in  the  toxicity  of  the  urine  after  a  cold  bath,  as  shown  by  Bouchard, 
Roque  and  Weil. 

2.  Heat  is  transferred  from  the  body  to  the  water  and  in  greater  quan- 
tity than  the  heat  produced,  so  that  a  fall  of  temperature  results.     This  is 
made  doubly  necessary    because  of  the  above    mentioned    increase  in  heat 
production  which  would  tend  to  increase  the  height  of  the  fever  if  it  were 
not  combated.     This  is  by  purely  mechanical  means,  i.  e.,  conduction.     The 
heat  of  the  body  is  transferred  to  the  water  which  will  take  up  an  exceed- 
ingly large  amount  without  being  greatly  warmed. 

Heat  elimination  is  increased  by  friction,  i.  e.,  the  body  is  constantly 
kept  in  a  condition  favoring,  the  abstraction  of  heat.  The  rubbing  produces 
vasodilatation  and  quickens  the  circulation.  These  conditions  bring  more 
blood  to  the  surface  which  is  exposed  to  the  cold  water.  The  same  condi- 
tions and  the  friction  itself  serve  to  give  a  sensation  of  warmth  to  the  skin 
and  so  prevent  chilling  and  the  resulting  retrostasis  of  blood. 

Indications.  These  effects  are  indicated  in  long  continued  asthenic  fevers, 
such  as  typhoid,  typhus  and  in  hyperpyrexia.  The  treatment  must  be  fre- 
quently repeated  over  a  considerable  length  of  time,  since  it  can  not  be 
hoped  that  the  source  of  toxemia  will  be  eradicated  by  a  few  applications. 

Short  Cold  applications  are  almost  always  accompanied  by  mechanical 
stimuli.  The  cold  mitten  friction  is  the  best  example  of  this  class. 

1.  Heat  production  is  increased  by  reason  of  the  action  of  the  thermic 
and  mechanical  stimuli  on  the  heat  centers. 

2.  The  contact  with  the  cold  water  is  of  too  brief  duration  to  abstract 


104 


FEVER  AND  ANTIPYRETIC  EFFECTS 


much  heat  from  the  body.  The  cooling  is  not  manifest  except  on  the  skin. 
Later,  heat  elimination  is  increased  because  of  the  vascular  reaction  in  the 
skin. 

Indications.  Short  sthenic  fevers,  as  grippe,  colds,  etc.,  or  where  the 
skin  is  cold  and  clammy,  for  the  purpose  of  warming  the  skin  and  raising 
the  blood  pressure.  This  sometimes  occurs  in  typhoid. 

Long  Hot.  Any  of  the  sweating  treatments  used  in  fevers  serve  to  illus- 
trate the  effects  of  this  class  of  measures. 

1.  Heat  production  is  increased  during  the  treatment,  at  least,  to  some 
extent.  The  atonic  reaction  which  follows  may  result  in  decrease  of  heat 
production. 

2  Heat  is  communicated  to  the  body.  This  is  the  chief  cause  of  the 
initial  rise  of  temperature  before  perspiration  becomes  well  established  and 
general.  Later,  heat  elimination  is  enormously  increased  because  of  the 
increased  circulation  in  the  skin  and,  especially,  by  the  evaporation  of  the 
perspiration.  This  latter  is  the  essential  effect  of  sweating  treatments. 

Temperature-raising:  value 


D    F 

W  H   R 

C    M    F 

9 

Crrt      TJ 

WC      T> 

.      1.     K. 

.  o.  K. 

Bath 

Cold 
Bath 

Temperature-lowering  value 

Fig.  28.  Diagram  showing  quantitative  relation  between  the 
temperature-raising  and  the  temperature-lowering  capacity  of 
different  treatments. 

Indications.  Sweating  treatments  are  indicated  in  the  first  stage  of  nearly 
all  fevers,  i.  e.,  at  the  onset.  It  is  at  this  time  that  the  initial  chill  occurs. 
They  are  useful  at  this  stage  in  such  fevers  as  measles,  influenza,  scarlet 
fever,  etc. 

Short  Hot.  Fomentations,  short  hot  packs  and  the  hot  evaporating  wet 
sheet  pack  are  examples  of  this  class  of  antipyretics.  Their  special  advan- 
tage is  the  preparing  of  the  skin  to  properly  react  to  suceedin^  cold  treat- 
ment. Heat  elimination  is  increased  through  the  warming  effect.  Some 
heat  is  communicated  to  the  body.  Heat  production  is  little,  if  at  all  influ- 
enced. Wherever  there  is  chilliness,  cyanosis  or  goose-flesh  in  febrile  disease, 
some  form  of  hot  application  must  be  used  before  resorting  to  cold,  since  in 
the  absence  of  the  former,  the  cold  may  have  a  decidedly  adverse  effect. 

In  addition  to  the  effects  noted  in  the  general  classes  of  treatments  dis- 
cussed above,  it  should  be  understood  that  by  proper  variations  in  the  manner 
of  giving  hydriatic  treatment,  it  is  possible  to  produce  any  desired  effect 
upon  the  heat  mechanism  and  upon  febrile  temperature.  In  the  case  of 
cold  treatments  these  variations  are  produced  by  changes  in  the  degree  of 


MECHANISM  OF  FEVER  PRODUCTION  105 

friction  used  and  in  the  quantity  of  cold  water  brought  in  contact  with  the 
skin  surface.  The  more  the  friction  and  the  less  the  contact  with  cold  water, 
the  greater  the  temperature  raising  capacity.  The  larger  the  amount  of 
cold  water  brought  in  contact  with  the  body,  provided  reaction  be  maintained, 
the  greater  the  temperature  lowering  capacity.  This  relation  is  graphically 
shown  in  (Fig.  28.)  The  proportion  of  each  block  below  the  dotted  cross 
line  indicates  the  relative  value  of  the  treatment  in  lowering  temperature  as 
compared  with  its  temperature  raising  value  indicated  by  the  proportion  of 
the  block  above  the  line. 

Mechanism  of  Fever  Production 

The  mechanism  of  the  production  of  fever  is  a  large  subject  and  one  some- 
what outside  of  the  scope  of  this  work.  There  are,  however,  a  few  points 
that  should  be  noted  in  order  to  gain  an  understanding  of  the  principles 
involved  in  the  treatment  of  fever,  i.  e.,  in  order  to  treat  such  conditions 
intelligently. 

Graham  Lusk 6  gives  the  following  discussion : — 

"A  high  fever  may  be  accompanied  by  an  increased  metabolism  of  only 
15  per  cent.  The  cause  of  the  fever  must  therefore  be  due  to  diminution 
in  the  ability  to  discharge  the  heat  produced.  In  further  support  of  this, 
Senator  has  shown  that,  the  fever  following  pus  injections  in  a  dog  begins  with 
a  retention  of  heat  within  the  body.  Nebelthau  found  that  when  the  heat 
discharge  of  a  normal  rabbit  was  called  100,  during  the  first  12  hours  of 
infection  in  which  the  temperature  rose  from  38.6°  to  40.1°,  the  discharge 
of  heat  was  but  96.3.  Assuming  the  heat  production  to  have  been  the  same 
in  these  two  periods  (as  was  actually  the  case  in  the  rabbits  of  May),  then 
the  heat  retained  would  account  for  the  pathological  increase  in  temperature. 
At  a  later  stage  the  discharge  of  heat  rose  to  equalize  its  production  at  the 
higher  temperature. ' ' 

In  the  state  of  lessened  heat  elimination  manifest  at  the  beginning  of 
most  fevers  lies  the  reason  for  the  initial  use  of  hot  applications  so  frequently 
advised  in  the  subsequent  pages  of  this  work. 

"Nebelthau  has  shown  a  fall  in  temperature  and  heat  production  in  a 
rabbit  whose  cord  was  divided  between  the  sixth  and  seventh  cervical  ver- 
tebrae, and  has  also  demonstrated  that  under  these  circumstances  infection 
with  erysipelas  of  the  pig  had  no  influence  on  temperature  or  heat  produc- 
tion. The  inference  is  that  the  febrile  toxines  act  through  the  higher  vaso- 
motor  centers,  whose  regulatory  control  is  lost  in  the  above  experiment. 

"A  kindred  interpretation  may  be  placed  on  the  experiments  of  Mendel- 
sen,  who  was  unable  to  produce  fever  through  pus  injections  when  the  dog 
was  under  the  influence  of  chloral  or  morphin,  although  such  treatment  in  a 
normal  animal  caused  a  rise  in  temperature  of  from  36.3°  to  39.9°  in  45  min- 
utes. Mendelsen  also  finds  a  constant  constriction  of  the  renal  blood  vessels 
in  fever. 

"In  intermittent  fever  profuse  perspiration  is  certainly  an  important  fac- 
tor in  the  reduction  of  temperature  at  the  end  of  the  febrile  stage. 

6    Science  of  Nutrition,  p.  255. 


106  FEVER  AND  ANTIPYRETIC  EFFECTS 

"It  may  be  concluded,  as  Krehl  emphatically  states,  that  insufficiency  of 
water  evaporation  plays  a  not  unimportant  role  in  the  febrile  rise  in  tem- 
perature. The  body  might  be  cooled  were  the  sweat  glands  freely  active. 

"The  production  of  heat  in  fever  may  be  greatly  increased  during  a  chill, 
and  a  rapid  rise  in  temperature  may  follow.  This  was  shown  by  Lieber- 
meister  in  a  case  of  malaria.  The  temperature  rose  from  36.9°  in  the  first 
half  hour  to  39.5°  at  the  end  of  another  hour,  while  the  carbon  dioxide  expired 
rose  from  13.85  grams  to  34.20  grams  per  hour.  This  was  a  case  of  chill 
with  shivering.  This  increased  metabolism  is  due  to  the  mechanism  of 
chemical  regulation.  The  blood  is  driven  from  the  skin  by  vasoconstriction, 
those  end-organs  of  the  skin  which  are  sensitive  to  cold  are  strongly  stimu- 
lated, with  the  result  that  there  is  a  reflex  increase  of  heat  production. 
That  this  is  true  is  shown  by  the  fact  that  if  the  cold  stimulation  be  removed 
by  supplying  a  warm  environment,  the  attending  phenomena  pass  off 
(Krehl)." 

Variations  that  Produce  Febrile  Temperature 
and  their  Relation  to  Treatment 

Any  unbalancing  of  thermoregulation  whereby  there  is  more  heat  produced 
than  is  eliminated  will  cause  a  rise  of  temperature.  It  will  be  seen  from 
this  that  there  are  several  possible  variations  in  these  two  elements  which 
might  be  the  cause  of  fever.  In  a  majority  of  fevers,  the  greater  difficulty 
at  first  is  in  the  faulty  heat  elimination.  A  rise  of  temperature  will  follow 
any  of  the  conditions  listed  below: — 

Heat  Production  Heat  Elimination 

1.  Increased Normal 

2.  Increased Increased,  but  less  than  heat  production 

3.  Increased Decreased 

4.  Normal      Decreased 

5.  Decreased Decreased,  but  more  than  heat  production 

These  variations  are,  perhaps,  largely  of  theoretical  interest.  However, 
there  is  a  practical  application  to  be  made  of  the  signs  and  symptoms  which 
indicate  a  decided  over-production  of  heat  or  a  marked  decrease  in  heat  elimi- 
nation. The  former  counter-indicates  vigorous  tonic  measures,  such  as  the 
cold  mitten  friction,  which  are  not  accompanied  by  heat  abstraction,  i.  e., 
more  or  less  prolonged  contact  with  cold  water.  The  latter  are  of  especial 
importance  in  revealing  a  condition  which  absolutely  counterindicates  the 
use  of  long  cold  applications,  and  in  many  cases  even  the  short  cold  friction 
unless  preceded  by  hot  applications.  In  cases  of  pyrexia,  the  following 
signs  indicate  a  great  increase  in  heat  production: — 

1.  Full  pulse  and  flushed  face. 

2.  A  hot,  dry  skin. 

A  consideration  of  these  will  at  once  reveal  the  fact  that  a  cold  mitten 
friction  would  be  inappropriate,  since  it  has  no  tendency  to  lower  blood 
pressure  also  because  the  treatment  stimulates  heat  production,  but  the  con- 
tact with  cold  water  is  of  too  brief  duration  to  abstract  much  heat  from  the 
body.  Neither  would  a  hot  application  or  a  sweating  treatment  best  meet 


HYDRIATIC  ANTIPYRETICS  107 

the  condition.    It  is  necessary  to  abstract  heat  from  the  body  by  some  more 
or  less  prolonged  cold  application. 

On  the  other  hand,  the  following  symptoms  show  a  decided  decrease  in 

heat  elimination: — 

1.  Cold  skin,  whether  dry,  or  moist  and  clammy. 

2.  Cyanosis. 

3.  Goose-flesh  appearance. 

4.  Chilly  sensations. 

5.  Shivering. 

Again,  consideration  of  these  conditions  reveals  the  fact  that  cold  appli- 
cations, unless  accompanied  by  vigorous  friction,  and  not  even  then  in  some 
cases,  will  greatly  increase  the  anemia  of  the  skin  and  the  internal  conges- 
tion which  exists  because  of  the  chilling.  In  these  cases,  hot  applications 
or  sweating  treatments  must  be  used  until  the  cyanosis  is  overcome  and  the 
blood  brought  back  to  the  surface,  thus  relieving  the  internal  congestion 
and,  at  the  same  time  imparting  a  sensation  of  warmth  to  the  body  and 
consequently  checking  the  shivering.  This  is  also  indicated  in  the  first 
stage  of  many  fevers  where  the  chill  has  actually  begun  or  where  chilly 
sensations  indicate  its  approach. 

In  general  then,  it  may  be  said  that  long  cold  applications  should  be  used 
where  great  increase  of  heat  production  is  the  chief  cause  of  fever;  and  hot 
applications  where  the  decided  decrease  of  heat  elimination  is  a  prime  factor 
in  the  fever.  The  following  lists  of  hot  and  of  cold  treatments  are  given  in 
the  order  of  their  efficiency  and,  when  properly  selected  and  suited  to  the 
individual  case,  the  cold  treatments  meet  the  first  indication  and  the  hot 
treatments  the  second  indication. 

Cold  applications  useful  in  febrile  conditions:— 

1.  Brand  bath. 

2.  Graduated  bath  with  friction. 

3.  Tepid  or  cool  bath. 

4.  Evaporating  wet  sheet  pack. 

5.  Cold  to  head  and  neck. 

6.  Ice  bag  or  cold  compress  to  heart. 

7.  Cold  compress. 

8.  Cold  rectal  irrigation  or  enema. 

9.  Cold  water  drinking. 

10.     Fresh  cold  air  in  the  sick  room. 

Hot  applications  which  may  be  used  to  reduce  fever  or  assist  the  cold 
applications: — 

1.  Hot  blanket  pack. 

2.  Hot  bath  (very  short) . 

3.  Hot  evaporating  sheet. 

4.  Fomentations  to  spine. 

5.  Fomentations  to  abdomen. 

?!  CoTd^tten^WctiSn  (reaction  simulates  the  effect  of  a  hot  applica- 
tion) . 


CHAPTER  XVII 

THE  TREATMENT  OF  FEVERS 

Typhoid  Fever 

Typhoid  fever  is  an  acute  infectious  disease,  more  or  less  self -limited, 
characterized  pathologically  by  a  localized  inflammation  of  the  lymphatic 
structures  of  the  intestines  and  a  general  distribution  of  the  bacteria  (bac- 
teriemia) ;  clinically,  by  fever  of  rather  long  duration  which,  at  the  onset, 
rises  gradually  in  stepladder-like  increase  and  gradually  subsides;  diarrhea, 
and  a  special  tendency  to  hemorrhage  and  perforation.  We  say  that  the 
disease  is  self-limited  because  it  is  one  of  those  infections  which  arouse  the 
body  to  the  production  of  antitoxines,  bacteriolysins,  agglutinins,  etc.,  so 
that  when  the  system  has  had  time  to  produce  these,  the  infection  is  over- 
come and  the  patient  recovers.  It  is  not  possible  to  abort  typhoid  fever  by 
therapeutic  means.  The  so-called  abortive  type  of  typhoid  fever  is  due  to 
some  peculiarity  of  the  individual  or  of  the  infection  and  not  to  any  treatment. 

The  chief  object  to  be  accomplished  in  the  treatment  of  typhoid  fever  is 
not  the  reduction  of  the  temperature,  but  the  sustaining  of  vital  resistance 
until  such  time  as  the  system  has  had  opportunity  for  the  production  of 
antibodies.  This  building  up  of  the  vital  resistance  is  accomplished  chiefly 
in  two  ways, — first,  by  stimulating  the  process  of  phagocytosis,  i.  e.,  increas- 
ing the  numbers  and  efficiency  of  the  leucocytes  in  the  peripheral  circula- 
tion, in  order  that  they  may  combat  the  infection,  the  bacteria  themselves. 
Second,  the  decrease  of  the  toxemia  by  increasing  the  oxidation  of  the  bac- 
terial toxines  and  hastening  their  elimination  in  an  incompletely  oxidized 
state.  The  body  poisons,  the  leucomaines,  are  taken  care  of  in  the  same  way 
and  by  the  same  means.  These  are  the  two  principal  objects  to  be  attained 
in  the  treatment.  The  reduction  of  temperature  is  only  incidental  to  these 
and  serves  as  a  practical  guide  to  the  completeness  of  these  results.  How- 
ever, in  the  use  of  medicinal  antipyretics,  the  degree  of  the  fever  in  no  way 
runs  parallel  with  the  accomplishment  of  these  essential  objects.  With  both 
quinin  and  the  coal  tar  products,  phagocytosis  is  interfered  with,  if  not 
wholly  abolished  and  the  toxemia  is  increased  because  of  a  decrease  in  the 
oxidation  and  elimination  of  the  poisons.  Under  the  use  of  hydrotherapy, 
rationally  employed,  typhoid  fever  presents  an  entirely  different  clinical 
picture  from  that  which  we  have  been  taught  to  regard  as  characteristic  of 
this  disease.  The  cold  bath  meets  practically  all  of  the  conditions  and  symp- 
toms which  require  special  attention.  The  heart  and  circulation  are  sus- 
tained and  invigorated,  the  nervous  system  is  aroused,  and  the  nervous 
symptoms,  usually  regarded  as  an  invariable  accompaniment,  either  do  not 


TYPHOID  FEVER 


109. 

appear  or  are  mitigated  in  severity.     The  emunctories  are  sustained  so  that 
elimination  is  greatly  increased. 

Treatment 

Since  the  cold  friction  bath  is  the  best  means  of  treating  typhoid  our  con- 
sideration  of  this  disease  will  largely  be  a  discussion  of  the  methods  ration- 
ale and  results  of  this  measure.  The  original  cold  friction  bath,  as'devised 
by  Brand,  consists  in  the  full  immersion  of  the  body  in  water  at  a  tempera- 
ture of  not  less  than  65°  F.  nor  more  than  70°  F.  As  advised  by  Brand  it 
continues  15  minutes,  during  which  time,  the  entire  skin  surface  immersed 
in  the  water,  with  the  exception  of  the  abdomen,  is  rubbed  vigorously  by 
the  attendants.  The  object  of  the  friction  is  the  production  of  reaction  so 
that  the  sensation  of  chilliness  is  abolished,  and  the  circulation  of  the  skin 
maintained,  thus  favoring  the  cooling  of  the  blocd.  If,  at  any  time,  the 
patient  becomes  cyanotic,  or  real  chilling  occurs,  as  indicated  by  continued 
shivering  and  chattering  of  the  teeth,  he  must  at  once  be  removed  from  the 
bath. 

As  to  the  appliances  necessary,  it  has  been  found  that  some  form  of  port- 
able bath  is  most  convenient.  Of  these,  there  are  two  forms  worthy  of 
description,— the  bath  tub  on  wheels  and  the  bed  tub.  The  former  is  made 
of  various  materials  and  sufficient  in  length  to  allow  the  full  extension  of  the 
patient  while  immersed  in  the  water  and  of  such  depth  that  the  patient 
is  covered  with  water  up  to  the  chin.  This  tub  can  be  wheeled  to  the 
side  of  the  bed,  being  placed  a  sufficient  distance  from  the  side  of  the  bed 
to  allow  of  two  attendants  reversing  the  patient  in  carrying  him  from  the 
bed  to  the  bath. 

The  Burr  Portable  Bath  is  probably  the  best  type  of  the  bed  bath.  It 
consists  of  two  parts — a  large  rubber  sheet  with  rings  attached  near  the 
margin  by  elastic  tapes,  and  a  light  wooden  crib  capable  of  being  folded 
into  a  compact  bundle.  The  rubber  sheet  is  first  slipped  under  the  patient 
and  brought  up  over  the  pillow,  being  tucked  along  the  sides  of  the  body. 
The  frame  is  then  unfolded,  placed  down  over  the  patient  so  as  to  rest  on 
the  mattress,  surrounding  the  patient,  pillow  and  rubber  sheet.  The  edges 
of  the  sheet  are  then  drawn  up  over  the  top  rail  and  fastened  to  the  lower 
rail  by  its  rings.  When  complete,  it  is  capable  of  holding  about  twenty 
gallons  of  water.  It  may  be  filled  by  either  a  pail  or  hose  attached  to  a 
faucet  and  emptied  by  a  siphon.  This  arrangement  demands  less  moving  of 
the  patient  than  any  other  form  of  bath. 

Before  being  immersed  in  the  cold  water,  the  head  and  face  of  the  patient 
are  bathed  in  ice  water.  If  the  tub  is  used,  it  is  necessary  to  provide  an 
invalid  ring  for  the  head  and  a  similar  cushion  or  water  pillow  should  sup- 
port the  nates.  If  the  patient's  skin  is  warm  on  entering  the  bath,  and  the 
friction  is  vigorous  and  kept  up  during  the  entire  period  of  immersion,  there 
is  little  danger  of  chilling  or  collapse.  If,  at  any  time,  this  should  occur, 
the  patient  must  be  immediately  removed  and  placed  in  a  dry  blanket,  the 
surface  being  vigorously  rubbed  until  the  skin  is  warm  and  reaction  fully 
established.  A  complaint  of  chilliness  on  the  part  of  the  patient  may  not 
be  an  indication  for  removal  from  the  bath.  The  appearance  of  goose-flesh, 


110  THE  TREATMENT  OF  FEVERS 

however,  necessitates  removal.  The  patient  should  not  be  allowed  to  remain 
in  the  bath  until  the  appearance  of  cyanosis  or  any  other  decided  symptom 
of  untoward  effects. 

While  the  Brand  bath  seems  to  give  the  best  results  with  young  vigorous 
persons,  where  treatment  can  be  begun  during  the  first  week,  yet  this 
method  is  not  applicable  to  those  cases  which  apply  for  treatment  during 
the  second  or  third  week,  since  they  have  already  become  so  weakened  that 
there  is  not  sufficient  vitality  to  fully  react  to  so  vigorous  a  means.  The 
Brand  bath  is  also  counterindicated  in  cases  of  much  reduced  vitality  from 
any  other  cause,  and  in  the  very  young  and  the  aged.  In  regard  to  the  use 
of  measures  other  than  the  strict  Brand  bath  Buxbaum  l  inclines  to  the  view 
that  the  essential  feature  is  the  obtaining  of  the  reaction  by  suiting  the  treat- 
ment to  the  needs  of  the  individual  case.  He  says,  "With  reference  to  the 
special  measures  to  be  employed,  the  desired  result  can  no  doubt  be  attained 
with  the  most  varied  hydriatic  procedures,  provided  the  thermic  and  mech- 
anical stimulations  are  graduated  in  accordance  with  the  indications  of  the 
individual  case.  Hence,  there  can  be  no  invariable  and  exclusive  routine." 

With  many  patients,  it  is  better  to  employ  a  bath  at  a  higher  temperature, 
the  graduated  bath  of  Ziemssen,  or  the  wet  sheet  pack,  cold  sponging,  com- 
presses, etc.  A  graduated  bath  begins  at  a  temperature  of  90°  or  even  95° 
F.  and  continues  for  half  an  hour,  or  longer,  during  which  time,  the  tem- 
perature is  gradually  lowered  by  the  addition  of  cold  water,  friction  being 
employed  as  soon  as  the  patient  complains  of  any  chilliness.  The  tempera- 
ture may  be  decreased  to  between  70"  and  80°  F.,  according  to  the  condition 
of  the  patient.  This  bath  is  just  as  effective  as  the  Brand  bath  in  the  reduc- 
tion of  the  fever;  in  fact,  it  is  a  mistake  to  suppose  that  the  colder  the  bath, 
the  greater  is  the  reduction  in  temperature.  This  is  not  the  case.  A  higher 
temperature  for  a  longer  time  may  reduce  the  fever  just  as  effectively  as  a 
lower  temperature  for  a  shorter  time.  There  is,  however,  this  very  essential 
difference,  that  the  stimulating  of  the  body  functions  is  greater  in  propor- 
tion to  the  degree  of  cold.  With  the  graduated  bath,  as  efficient  and 
thorough  stimulation  is  not  obtained  as  with  the  Brand  bath.  Whenever  the 
temperature  exceeds  102.5°  or  103°  F.  the  bath  should  be  repeated.  In 
practice,  it  has  been  found  that  repetition  every  three  or  four  hours  gives 
the  best  results. 

Of  other  methods,  the  following  are  useful  in  special  cases  or  where  the 
ideal  treatment  can  not  be  carried  out: — 

1.  The  Wet  Sheet  Pack  is  perhaps  less  objectionable  to  the  patient  than 
a  cold  bath.     Liebermeister  claims  that  four  wet  packs  of  10  minutes  dura- 
tion each,  are  equivalent  to  a  cold  bath  of  10  minutes;  and  Baruch,  that  six 
such  packs  are  equivalent  to  a  Brand  bath.      The  sheet  should  be    wrung 
from  ice  water  or  very  cold  waterj     It  is  applied  in  the  usual  manner  and 
after    the    initial   warming,    maintained  at  the   evaporating    stage,    being 
renewed  by  sprinkling  of  more  cold  water  on  the  sheet.      The  rapidity  of 
evaporation  may  be  increased  by  fanning. 

2.  The  Cold  Towel  Rub  given  with  a  towel  well  filled  with  very  cold  water 
is  an  excellent  substitute  for  the  wet  sheet  pack.     The  use  of  the  wet  sheet 

1     Cohen — System  of  Physiologic  Therapeutics,  Vol.  IX,  p.  134. 


TYPHOID  FEVER  ln 

pack  necessitates  more  or  less  moving  of  the  patient  which  is  not  the  case 
with  the  cold  towel  rub.  The  wet  towel  may  be  applied  several  times  to 
the  same  part  and  even  ice  water  used. 

3.  The  Ice  Rub.     H.  A.  Hare  has  employed  the  ice  rub  with  good  success. 
A  flat  piece  of  ice  is  wrapped  in  thin  linen  or  gauze  and,  by  rapid  movements, 
different  parts  of  the  body  are  gone  over.     He  recommends  this  application 
to  the  back  only,  avoiding  the  extremities.     Others,  however,  utilize  it  as  a 
general  measure  in  place  of  the  cold  bath. 

4.  Cold  Sponging  and  Cold  Affusions  are  of  decided  advantage  in  those 
cases  where  the  bath  or  pack  can  not  be  used.     Cold  affusions  to  the  head 
are  of  great  service  in  delirium  and,  in  fact,  whenever  nervous  symptoms 
are  unduly  prominent. 

5.  The  Cold  Abdominal  Compress  is  an  efficient  means  and  should  be  kept 
in  place  between  other  treatments.    The  best  results  from  this  are  obtained 
when  the  Winternitz  coil  is  placed  over  one  layer  of  the  compress.      The 
steady  flow  of  cold  water  through  the  coil  renders  unnecessary  the  constant 
renewal  of  the  compress,  which  requires  so  much  time  on  the  part  of  the 
nurse.      It  also  avoids  the  shock  from    the    renewal    which    prevents   the 
patient  from  completely  relaxing  for  any  length  of  time. 

6.  The  Cold  Enema,  or  continuous  rectal  irrigation  is  another  very  effici- 
ent means.    Since  it  has  been  shown  by  Schuller  that  the  cold  enema  always 
produces  more  or  less  retrostasis;  this  treatment  may  be  productive  of  harm; 
Kellogg    mentions  a  case  with  a  temperature  of  104.2°  F.  in  which    three 
large  enemata  at  66°,  62°,  62°  F.,  given  in  rapid  succession,  reduced  the  tem- 
perature to  99.2°  within  one  hour.      Such  rapid  and  extreme  reduction  of 
temperature  may  be  dangerous  and  is  hardly  to  be  recommended  for  general 
use. 

7.  The  Leiter  Coil  or  Cold  Winternitz  Coil  to  the  head  is  a  very  efficient 
means,  both  of  preventing  the  rise  of  temrerature,  and  alleviating  the  ner- 
vous symptoms.    It  should  be  used  between  other  treatments.    The  ice  bag 
or  Leiter  coil  over  the  heart  is  also  serviceable,  especially  where  the  pulse 
is  very  rapid  and  weak. 

Hot  Treatment.  In  those  cases  where  chilliness  and  cyanosis  are  produced 
by  the  cold  bath  and  other  cold  applications,  or  in  which  this  condition  is 
more  or  less  constant,  it  is  necessary  to  thoroughly  warm  the  skin,  bring- 
ing the  blood  to  the  sift-face  and  effectually  reducing  the  extreme  internal 
congestion  before  any  cold  application  can  be  made  with  success.  For  these 
preliminary  hot  treatments,  one  may  use  fomentations,  the  hot  pack,  the 
hot  evaporating  sheet  or  hot  sponging,  according  to  the  circumstances  and 
indications.  They  may  be  aided  by  hot  water  drinking.  During  the  cold 
treatment,  hot  water  bottles  and  spine  bags  should  be  used  to  keep  the  limbs 
warm  and  prevent  chilling.  The  skin  should  be  red  and  warm  and  the 
patient  feel  warm,  before  any  cold  treatments  are  given.  The  cold  mitten 
friction  and  the  cold  towel  rub  are  valuable  adjuncts  to  the  hot  applications, 
since  they  increase  the  warming  of  the  skin  more  than  they  cool  the  blood. 
Cold  applications,  such  as  ice  bags  and  ice  caps  should  be  applied  to  the  head 
and  over  the  carotids,  whenever  any  decidedly  hot  applications  are  made. 


112  THE  TREATMENT  OF  FEVERS 

These  help  to  prevent  any  rise  of  temperature  while  the  patient  is  being 
prepared  by  the  hot  treatment  in  order  to  react  to  the  succeeding  cold. 

The  Diagnostic  Bath.  Baruch  and  Kellogg  claim  for  the  cold  bath,  a  cer- 
tain value  as  a  diagnostic  means  when  employed  during  the  first  week  of 
the  fever.  Baiuch  uses  the  following  method:  When  the  rectal  tempera- 
ture reaches  103°  F.  and  other  symptoms  indicate  typhoid  fever,  the  patient 
is  tubbed  in  water  at  90°  for  10  minutes,  being  rubbed  continuously.  Tem- 
perature is  taken  £  hour  after  the  bath  and  again  4  hours  after  the  bath. 
If,  at  the  termfnation  of  this  time,  the  temperature  still  registers  103°  or 
over,  the  patient  is  bathed  in  water  at  85°,  and  the  temperature  recorded 
as  before.  If  it  still  remains  at  103°  or  above,  a  third  bath  at  80°  is  given, 
and  the  fourth  time  at  75°,  employing  friction  with  each.  Baruch's  experi- 
ence with  this  bath  leads  him  to  believe  that,  if  the  temperature  is  reduced 
more  than  two  degrees,  typhoid  fever  is  improbable,  while  if  there  is  little 
or  no  reduction,  the  diagnosis  becomes  more  positive. 

Rationale  of  the  Cold  Bath.  The  brunt  of  the  infectious  process  and  tox- 
emia in  typhoid  fever  falls  upon  the  nervous  system,  the  circulatory  system 
and  the  kidneys. 

1.  The  Nervous  System.     In  fever  it  is  largely  because  of  the  imperfect 
action  and  control  exercised  by  the  nervous  system  that  many  of  the  body 
functions  are  deranged.     It  fails  to  control  the  heat  mechanism,  the  vaso- 
motors  are  disturbed,  glandular  activity  is  depreciated.    The  toxemia  is  the 
principal  cause  of  the  derangement  of  the  nerve  centers.     The  congestion 
about    these    centers    which  occurs  in  nearly  all  fevers  only  increases  the 
volume  of  toxines  in  the  blood  supplying  them.    The  nerve  cells  are  benumbed 
and  lethargic,  or  they  are  irritable,  restless  and  overactive  in  an  irregular 
sort  of  way.     The  high  temperature  adds  to  the  intensity  of  this  state.     It 
is  necessary  to  eliminate  the  toxines  and  arouse  the  nervous  system  from 
its  stupor,  stimulating  it  to  a  normal  activity  and  by  tonic  means,  relieving 
its  irritability  so  that  rest  may  be  secured. 

All  these  effects  are  produced  by  the  cold  bath.  The  more  profound  the 
stupor  and  intense  the  delirium,  the  more  marked  the  relief  experienced. 
Quiet,  refreshing  sleep  usually  follows  each  tubbing  or  other  vigorous  cold 
treatment.  Subsultus  and  carphologia  are  relieved.  Headache,  hebetude 
and  apathy  are  succeeded  by  a  brightening  of  the  mental  powers.  Post- 
febrile  insanity  and  mental  weakness  are  less  liable  to  occur  where  hydro- 
therapy  is  systematically  employed.  » 

All  of  the  medicinal  antipyretics  dull  and  stupify  the  nervous  system. 
The  centers  are  not  apprised  of  the  danger  and  so  can  not  properly  regulate 
protective  functions. 

2.  The  Circulatory  System.     Heart  failure  is  that  to  which  we  have  been 
taught  to  ascribe  all  the    failures  in  the  circulation;    and  it  is  toward  the 
heart  muscle  that  many  medicinal  agents,  designed  to  act  upon  the  circu- 
lation, are  directed.     This  idea  has  resulted  in  the  deluging  of  the  system 
with  strychnin,    digitalis  and  the  like,  and  the  already    overworked    heart 
has  been    compelled  to  do  double   service  to  no  avail.      That   this    idea  is 
almost  wholly  erroneous  has  been  quite  fully  discussed  in  the  previous  part 
of  this  work. 


TYPHOID  FEVER  113 

Romberg  and  Passler  have  shown  that  the  chief  danger  to  the  circulation 
in  infectious  diseases  comes  through  paralysis  and  derangement  of  the  vaso- 
motors,  and  is  not  due  to  any  damage  to  the  heart  itself.     Passler  further 
claims  that  this  derangement  is  caused  by  loss  of  the  control  exercised  by 
the  vasomotor  center  in  the  medulla;    the  spinal  centers,  peripheral  vaso- 
motor  nerves  and  the  muscles  remaining  intact.    Reflex  effects  are  still  possi- 
ble.    The  heart  is  not  at  fault,  but  there  is  an  absence  of  the  natural  physio- 
logic resistance  normally  maintained  by  the  proper  tone  of  the  blood  vessels, 
together  with  the  loss  of  the  rhythmic  action  of  the  peripheral  heart.     Hare 
very   aptly  compares  the  heart  and  vasomotors  of  the  circulatory  system, 
respectively,  to  a  locomotive  and  the  resistance  offered  to  its  driving  wheels. 
He  says,  "The  locomotive  is  intended  to  meet  and  stand  any  resistance,  and 
if  the  resistance  is  removed  by  slippery  rails,  the  wheels  fly  around  ineffect- 
ually,   racking  the  machinery  and   destroying  its  usefullness.      From    the 
above,    some  important   diagnostic  and  therapeutic  facts  are  learned:    (1) 
that  a  rapid  pulse  may  be  due  in  no  way  to  a  disordered  heart,  but  to  vaso- 
motor relaxation;  (2)  that  the  proper  way  to  treat  this  rapid  pulse  is  to  put 
sand  on  the  track  and  increase  the  resistance,  and  not  to  make  more  steam — 
or  give  digitalis — which  only  cause  the  engine,  or  heart,  to  work  away  on 
slippery  rails  with  more  wear  and  tear,  and  make  no  progress."     That  this 
wear  and  tear  may  be  considerable  and  result  in  a  weaker  and  more  rapid 
pulse,  any  one  may  observe  who  will,  after  1-60  grain  of  strychnin  has  been 
administered  to  a  typhoid   patient  every  three  hours  for  a  week  or  more, 
discontinue  the  drug,  recording  the  blood  pressure  before  and  after  discon- 
tinuance of  the  strychnin,  by  means  of  some  accurate  blood  pressure  instru- 
ment.    Indeed,  the  change  for  the  better  is  so  marked  that  it  can  be  very 
readily  appreciated  by  the  finger  without  other  aid.     In  one  case  that  came 
under   the    author's    observation,    this   was   so   marked   and    appeared   so 
promptly,  that  it  was  observed  at  once  by  both  the  day  and  the  night  nurses. 

The  cold  friction  bath  meets  the  indication  presented  by  the  deranged 
vasomotors  more  fully  than  is  possible  with  any  other  means.  It  stimulates 
the  blood  vessels  to  normal,  rhythmic  action  and  relieves  the  heart  of  the 
excessive  burden  imposed  upon  it  by  their  failure.  In  typhoid  fever,  the 
blood  is  very  much  reduced  in  quality.  The  red  cells  and  hemoglobin  are 
decreased,  the  latter  to  a  greater  extent  than  the  former,  especially  during 
convalescence.  There  is  a  decided  leucopenia,  the  white  cells  being  decreased 
in  number  one-third,  or  even  more  than  one-half.  The  blood  is  laden  with 
acid  poisons  and  is  therefore  reduced  in  alkalinity  (Bireger) .  The  amount 
of  toxic  extractives  in  the  blood  has  been  shown  by  Robin  to  be  doubled  or 
trebled  in  case  of  fevers.  We  have  already  quite  extensively  discussed  the 
effect  of  the  cold  bath  on  the  composition  of  the  blood.  Suffice  it  to  say 
that  observations  made  by  Strasser,  Breitenstein,  Baruch  and  others  prove 
conclusively  that,  in  typhoid  fever,  every  constituent  of  the  blood  is  favor- 
ably influenced  by  the  cold  friction.  The  red  cells  in  the  peripheral 
circulation  are  greatly  increased,  the  whitfe  cells  increased  as  high  as  two 
or  threefold,  the  alkalinity  is  restored  and  acid  products  decreased.  Be- 
cause of  these,  normal  nutritive  changes  proceed  more  promptly. 

3.  The  Kidneys.  Elimination  in  febrile  conditions  is  very  defective. 
The  quantity  of  urine  is  decreased  and,  while  there  may  be  an  increase  in 


114  THE  TREATMENT  OF  FEVERS 

the  solid  constituents,  it  is  still  quite  insufficient  to  prevent  the  accumulation 
of  toxic  wastes  in  the  blood  and  tissues.  During  convalescence,  the  solids 
of  the  urine  increase  from  10  to  20  per  cent,  or  more,  over  the  amount 
excreted  during  the  febrile  period.  The  poisonous  wastes  are  more  insoluble 
than  those  of  little  or  no  toxicity  and  so  require  a  larger  quantity  of  the 
solvent,  water,  for  their  efficient  elimination. 

The  cold  bath  greatly  increases  diuresis.  The  quantity  of  solvent  is 
increased,  thus  increasing  the  toxines  eliminated.  But  this  alone,  does  not 
account  for  the  great  increase  in  the  toxicity  of  the  urine  under  the  bath 
treatment.  While  the  poisons  of  the  urine  in  typhoid  fever  are  double  the 
normal  amount,  Roque  and  Weil  found  them  increased  five  times  after  the 
cold  bath.  Bouchard  also  found  the  toxic  co-efficient  of  the  urine  greatly  in- 
creased by  the  cold  bath.  Robin,  in  one  case,  found  the  urea  increased  to 
20  per  cent.  On  the  contrary,  antipyretic  drugs  diminish  the  excretion  of 
urea  and  nitrogen.  The  liver  in  those  cases  dying  after  treatment  with  an- 
tipyrin,  is  said  to  be  heavier  than  the  liver  of  those  dying  after  the  cold 
bath  treatment.  These  drugs  produce  granular  and  fatty  changes  in  the 
liver  and  kidneys. 

The  respiratory  elimination  of  COa  and  intake  of  oxygen  are  decreased  in 
fevers,  the  amount  of  the  decrease  being  in  inverse  proportion  to  the  sev- 
erity of  the  fever.  This  is  due,  of  course,  to  the  lessened  capacity  of  the 
body  tissues  to  utilize  oxygen.  Both  oxygen  absorption  and  carbon  dioxide 
elimination  are  enhanced  by  the  cold  bath.  Robin  found  the  increase 
approximating  20  to  30  per  cent  above  the  usual  amounts  in  typhoid 
fever.  That  all  these  results  are  beneficial,  needs  no  argument.  There  is 
no  organ,  tissue  or  function  not  favorably  influenced  by  the  hydriatic  treat- 
ment of  typhoid  fever.  Because  of  the  maintenance  of  the  vital  resistance 
and  the  elimination  of  toxines  during  the  febrile  period,  convalescence  is 
much  shortened  when  cold  baths  have  been  used. 

Counterindications  and  Treatment  of  Complications 

Pneumonia.  The  cold  bath  is  counterindicated  in  pneumonia  of  the  lobar 
type.  The  case  should  be  treated  as  far  as  possible  as  simple  pneumonia 
alone  would  be  treated.  Fomentations,  cold  compresses,  alternate  hot  and 
cokl  applications,  the  ice  pack  to  the  chest  and  such  means  are  applicable 
where  the  pneumonia  arises  as  a  complication  and  may  be  used  in  much  the 
same  manner  as  is  ordinary  pneumonia.  Special  attention  must  be  given 
to  the  extremities.  They  should  be  kept  warm  and  the  circulation  active. 
The  cold  mitten  friction,  wet  towel  rub,  sponging  and  affusions  are  service- 
able in  place  of  the  bath.  Hypostatic  pneumonia  may  be  treated  by  alter- 
nate hot  and  cold  applications,  cold  affusions  or  ablutions  to  the  back.  The 
warm  bath  graduated  down  to  90°  F.  may  be  used. 

Pleurisy.  This  condition  absolutely  counterindicates  the  use  of  the  cold 
bath.  No  cold,  whatever,  should  be  applied  to  the  chest  over  the  inflamed 
area,  until  the  acute  stage  is  passed,  that  is,  for  2  or  3  days.  However, 
the  cold  towel  rub  and  cold  mitten  friction,  sponging,  etc.,  should  be  kept 
up  as  usual,  avoiding  only  the  skin  surface  over  the  inflamed  pleura  for 
the  first  2  or  3  days.  If  the  cold  baths  are  continued,  or  large  cold  compres- 


TYPHOID  FEVER  115 

ses  used  to  the  abdomen,  a  mild  pleurisy  may  become  so  fixed  as  to  require 
months  for  the  eradication  of  the  chronic  inflammation. 

Nephritis.  Contrary  to  what  might  be  expected,  the  use  of  the  cold  bath 
is  not  wholly  counterindicated  in  this  condition.  Mild  cases  of  nephritis 
improve  under  the  Brand  bath.  If  the  nephritis  is  severe,  the  graduated 
bath  may  be  substituted.  Yogi's  experience  demonstrates  that  nephritis  is 
less  common  in  those  treated  by  the  Brand  bath  and  also  that  the  mortality 
is  less  in  those  having  nephritis.  Both  the  urine  and  urea  increase  in  quan- 
tity and  the  albumen  decreases  under  the  effects  of  the  cold  bath.  Venous 
congestion  of  the  kidneys  is  conducive  to  nephritis,  albuminuria  and  the  for- 
mation of  casts.  This  condition  is  relieved  by  the  stimulation  of  the  circu- 
lation and  derivation  secured  by  the  cold  friction. 

Hemorrhage.  The  cold  bath  must  be  discontinued  as  soon  as  this  condition 
becomes  apparent,  principally  because  of  the  rest  needed.  The  limbs  should 
be  kept  warm  and  some  sort  of  cold  application  placed  over  the  abdomen. 
We  believe  the  most  satisfactory  measure  is  the  Winternitz  coil.  This  does 
away  with  the  shock  occasioned  by  the  renewing  of  cold  compresses  and  the 
temperature  can  be  more  accurately  gauged  and  more  perfectly  controlled 
than  with  the  ice  bag.  After  the  recovery  from  the  hemorrhage,  it  is  best 
to  permanently  discard  the  use  of  the  bath,  substituting  sponging,  affusions, 
the  cold  towel  rub,  etc. 

Perforation.  Here,  as  in  hemorrhage,  the  cold  bath  must  be  discontinued, 
the  patient  being  treated  by  rest  and  means  used  to  control  the  shock,  so 
that  operation  may  be  done  as  soon  as  possible.  If  peritonitis  supervenes, 
it  becomes  the  chief  objective  point. 

The  reduction  in  mortality  from  typhoid  since  the  introduction  of  the  cold 
bath  has  not  been  due  to  reduction  in  the  mortality  from  hemorrhage  and 
perforation.  According  to  Hare  2  the  mortality  from  these  causes  before 
and  after  the  introduction  of  the  Brand  bath  is  practically  the  same.  The 
mortality  from  all  other  causes  was  much  less,  dropping  from  9.7  to  3.4  per 
cent  and,  in  spite  of  no  change  from  the  above  mentioned  conditions,  there 
was  a  total  decrease  in  mortality  of  nearly  50  per  cent. 

Menstruation.  The  menses  frequently  cease  during  severe  febrile  condi- 
tions, but  cases  in  which  it  has  continued  have  been  successfully  treated  by 
cold  baths,  and  under  this  treatment,  cases  of  pregnancy,  complicated  by 
typhoid,  have  been  carried  to  a  successful  issue. 

Tympanites.  The  cold  bath  greatly  relieves  this  condition.  The  continu- 
ous use  of  the  ice  water  coil,  interrupted  every  hour  or  two  by  a  fomenta- 
tion, gives  great  relief.  The  asafcetida  or  turpentine  enema  should  not  be 
omitted  where  more  energetic  means  are  needed. 

Mortality  and  Statistics 

Modern  methods  in  the  rational  treatment  of  disease  have  accomplished 
few  more  striking  changes  than  that  accompanying  the  hydriatic  treatment 
of  typhoid  fever.  The  reduction  in  mortality  compares  quite  favorably  with 
the  lessened  fatality  in  small  pox  since  the  introduction  of  vaccination  and 
that  of  diphtheria  since  the  employment  of  antitoxine. 

2    Brisbane  Hospital,  Queensland,  1882  to  1896. 


116  THE  TREATMENT  OF  FEVERS 

Under  the  ordinary  expectant  plan  with  administration  of  medicinal  anti- 
pyretics, statistics  from  Germany  show,  among  11,124  cases,  a  mortality  of 
21.7  per  cent.  In  another  collection  of  27,051  cases,  there  was  a  mortality 
of  17.45  per  cent.  In  still  another  collection  of  80,140  cases,  there  was  a 
mortality  of  19.23  per  cent. 

In  one  division  of  the  German  army,  during  17  years  among  1970  cases, 
the  mortality  was  26.3  per  cent.  In  the  English  army  for  6  years,  ending 
with  1877,  there  was  a  mortality  from  typhoid  of  32  per  cent.  In  recent 
years,  Delafield  shows  a  mortality  of  26  per  cent  from  the  New  York  Hos- 
pitals. And  throughout  American  cities,  the  mortality  from  typhoid  fever 
is  claimed  to  be  from  25  to  40  per  cent,  In  the  typhoid  wards  of  the  John 
Hopkins  Hospital,  during  the  first  10  years,  9  of  which  is  since  the  intro- 
duction of  hydrotherapy,  Osier  reports  among  829  cases,  a  mortality  of  7.5 
per  cent.  During  the  first  year  of  this  time,  the  cases  were  treated  by  the 
ordinary  expectant  plan  and  moreover,  this  series  includes  all  cases  admitted, 
those  dying  within  1  or  2  days  and  those  diagnosed  at  autopsy.  From  the 
Brisbane  Hospital,  Hare  reports  a  typhoid  mortality  of  14.8  per  cent  previous 
to  the  introduction  of  hydrotherapy  and  7.5  per  cent  since  its  employment. 

In  1887,  Brand  gathered  statistics  of  19,017  cases,  showing  under  all  forms 
of  hydriatic  treatment,  a  reduction  in  mortality  from  21.8  per  cent  to  7.8 
per  cent.  In  another  series  of  cases  collected  by  Brand  and  enlarged  by 
Baruch,  in  which  the  strict  cold  bath  treatment  was  used,  Baruch  claims  a 
reduction  of  mortality  to  3.9  per  cent. 

In  the  division  of  the  German  army  above  referred  to,  the  mortality  under 
the  strict  Brand  system  was  reduced  from  26.3  per  cent  to  4.3  per  cent. 
Baruch  further  claims  that  among  1223  cases  treated  only  by  apostles  of 
the  Brand  system,  there  was  a  reduction  in  mortality  to  1  per  cent  (12  cases) 
and  that  '  'not  one  of  these  twelve  deaths  occurred  in  any  case  that  came 
under  treatment  before  the  fifth  day." 

Contrary  to  what  might  be  expected,  the  mortality  is  less  in  private 
practice  than  in  hospitals.  This  is  doubtless  because  the  cases  come  under 
observation  at  once  and  can  be  treated  from  the  beginning.  The  same  is 
true  of  army  and  navy  hospitals  where  all  indispositions  are  at  once  investi- 
gated by  the  medical  officer. 

The  statistics  gathered  by  Baruch 3  relative  to  the  mortality  from  typhoid 
fever  under  the  varying  methods  are  the  most  extensive  on  record.  The 
reduction  in  mortality  seems  to  depend  upon  (1)  the  strict  employment  of 
hydrotherapy  by  the  cold  bath  method  where  cases  come  under  observation 
before  the  fifth  day;  (2)  the  discarding  of  all  medicinal  antipyretics;  (3) 
judicious  employment  of  various  forms  of  hydrotherapy  where  cases  can  not 
be  treated  from  the  beginning;  (4)  private  practice. 


Malaria 

Since  this  disease  is  of  an  "infectious"  nature,  being  due  to  the  malarial 
plasmodium,  treatment  must  be  directed  toward  the  destruction  of  the  para- 

3     Baruch — Principles  and  Practice  of  Hydrotherapy,  p.  202. 


MALARIA  117 

site.  This  may  be  accomplished  in  either  of  two  ways, — first,  by  the  toxic 
action  of  quinin  and  second,  by  the  phagocytic  action  of  the  white  blood 
cell.  That  quinin  does  kill  the  parasite  and  thereby  check  the  disease,  no 
one  can  dispute.  But  that  it  also  fails  of  effecting  a  cure  in  by  far  the 
larger  number  of  chronic  cases  and  many  of  the  acute  cases,  is  also  indisput- 
able, being  witnessed  by  the  experience  of  all  practitioners  whose  practice 
brings  them  in  contact  with  this  disease.  The  last  word  concerning  malaria 
has  yet  to  be  spoken.  It  would  seem  that  giving  quinin  in  an  acute  case 
which  has  not  previously  been  taking  a  course  of  quinin,  if  so  administered 
that  there  is  a  maximum  dose  in  the  blood  just  previous  to  sporulation  which 
produces  the  chill,  stopping  there,  no  more  being  given  until  the  proper  time 
before  the  next  expected  paroxysm,  is  productive  of  good  results.  However, 
it  often  fails  in  the  estivo-autumnal  type,  since  it  is  uncertain  just  when  a 
paroxysm  may  be  expected,  sporulation  being  irregular  so  that  the  above 
program  can  not  always  be  carried  out  successfully.  It  has  also  been  shown 
that  quinin  fails  of  its  best  results  or  fails  altogether  where  it  has  previously 
been  administered  for  some  time  as  a  prophylactic,  or  in  the  treatment  of 

other  attacks. 

• 

The  following  experience 4  related  by  Dr.  E.  R.  Stitt,  a  United  States  Navy 
Surgeon,  is  worthy  of  careful  thought: — 

"While  in  camp  along  the  canal  route,  we  had  a  few  cases  of  malaria. 
These  were  immediately  treated  with  large  doses  of  quinin,  and  without 
exception  they  responded  promptly  and  satisfactorily  to  such  treatment. 
The  only  member  of  the  party  who  insisted  on  taking  quinin  prophylactically 
was  Colonel  Ludlow,  the  head  of  the  commission;  and  strange  to  say,  he 
was  the  only  one  who  had  malaria  on  the  trip  home." 

"To  those  who  have  thought  of  quinin  prophylaxis  as  a  true  preventive 
the  following  instance  is  instructive: — 

"On  May  20,  1906,  a  battalion  of  marines,  numbering  398,  was  organized 
at  Philadelphia.  Seventy-five  per  cent  of  the  force  was  made  up  of  recent 
recruits  "from  the  Middle  West.  Leaving  Philadelphia  May  21,  Colon  was 
reached  May  28.  On  June  4  the  battalion  was  disembarked  at  Colon  and 
stationed  for  a  time  at  Camp  Elliott,  which  is  situated  about  25  miles  from 
Colon  and  which  was  comparatively  free  from  mosquitoes.  Later  on,  three 
companies  were  stationed  at  Camp  Reed,  5  miles  from  Panama,  at  which 
place  mosquitoes  were  numerous  and  troublesome. 

"On  July  6,  after  a  service  of  practically  one  month  on  the  Isthmus,  the 
marines  returned  to  the  ship  (U.  S.  S.  Columbia).  During  the  month's  en- 
campment, 9  grains  of  quinin  had  been  served  out  daily  as  a  prophylactic. 
In  addition,  such  measures  as  head-nets  for  those  on  night  sentinel  duty  and 
inspection  of  mosquito  nets  about  the  men  sleeping  in  tents  had  been  in 
force.  There  was  very  little  malaria  reported  from  these  men  while  on  the 
Isthmus. 

"The  ship  sailed  from  Colon  on  the  night  of  July  7.  On  the  first  day  out, 
20  cases  of  malaria  were  admitted  to  the  sick  list,  the  next  day  53,  and  the 
third  day  45.  In  consequence  of  what  appeared  to  the  medical  officer  to  be 
universal  infection  among  the  men,  10  grains  daily  of  quinin  were  adminis- 

4    Journal  of  American  Medical  Association,  May  23,  1908,  p.  1683. 


118  THE  TREATMENT  OF  FEVERS 

tered  to  every  one  as  a  prophylactic.  Notwithstanding  this  almost  curative 
dosage  of  quinin,  the  condition  of  the  men  was  such  when  the  ship  arrived  at 
San  Juan,  July  13,  that  it  was  deemed  necessary  to  get  the  men  out  of  the 
tropics,  as  several  cases  of  a  pernicious  type  and  two  of  blackwater  fever 
had  appeared.  Accordingly  the  ship  sailed  for  Boston,  July  16. 

"Notwithstanding  the  prophylactic  use  of  quinin,  under  military  observa- 
tion, for  those  who  were  not  cinchonized,  there  were  215  acute  malaria 
paroxysms  among  298  men  during  the  five  days'  trip  from  San  Juan  to  Bos- 
ton. About  100  men  of  the  original  398  had  been  transferred  to  other  ships 
and  stations  prior  to  the  sailing  of  the  Columbia  for  Boston.  The  character 
of  the  paroxysms  was  atypical — there  was  no  frank  chill.  The  men  would 
feel  fairly  well  until  shortly  before  an  attack — they  would  then  complain  of 
chilliness  and  weakness  and  either  lie  down  or  fall  down  in  a  heap  on  deck. 
Passed  Assistant  Surgeon  Butler,  U.  S.  N.,  states  in  a  report,  that  when 
the  men  arrived  at  Boston  so  many  were  anemic  and  weak  that  they  were 
unfit  to  return  to  the  tropics.  Dr.  Butler  also  noted  the  fact  that  these 
cases  did  not  seem  to  respond  at  all  satisfactorily  to  quinin  even  when  given 
hypodermaticaMy.  Before  the  cases  became  so  numerous,  blood  examina- 
tions were  made  and  the  form  of  malaria  was  considered  to  be  chiefly  ter- 
tian. The  clinical  features,  however,  would  indicate  that  there  was  estivo- 
autumnal  infection  in  many  of  the  cases. 

"In  considering  the  experience  of  these  marines  who  were  given  prophy- 
lactic, I  might  even  say  curative,  doses  of  quinin  during  a  period  just  exceed- 
ing a  month,  and  when  this  was  discontinued  during  the  days  of  July  7,  8,  9 
and  10,  showed  an  extensive  malarial  morbidity,  the  question  naturally  pre- 
sents itself  as  to  the  explanation  of  this.  Furthermore,  we  must  note  the 
fact  that  resumption  of  quinin  prophylaxis  at  this  time  in  those  not  cinchon- 
ized apparently  had  little  effect  in  checking  the  outbreak,  and  that  when 
quinin  was  administered  in  curative  doses,  at  times  hypodermatically,  it  did 
not  seem  to  control  infection  as  is  usual.  It  is  common  experience  that 
malaria  responds  readily  and  promptly  to  quinin  properly  administered.  I 
can  not  but  believe  that  malarial  parasites  may  develop  a  resistance  to  qui- 
nin. 

'  'Browning,  reporting  recent  work  in  Ehrlich's  laboratory,  states  that  when 
mice  infected  with  trypanosomes  were  not  given  sufficient  doses  to  destroy 
the  flagellates,  these  protozoa  developed  a  resistance  to  the  therapeutic 
agent  during  the  time  their  development  was  held  in  abeyance.  A  most 
startling  discovery  was,  too,  that  these  trypanosomes  retained  their  chemo- 
resistance  through  numberless  generations.  After  passage  during  a  period 
of  14  months  through  144  mice  these  last  generations  of  trypanosomes  still 
retained  their  immunity  to  the  exciting  drug.  Browning  experimented  with 
atoxyl,  parafuchsin  and  trypan  blue.  Experiments  with  paramecium  have 
also  shown  that  these  ciliates  may  develop  marked  resistance  to  agents 
primarily  toxic  to  them." 

It  is  a  well  known  fact  that  while  quinin  kills  the  plasmodium,  it  also  kills 
the  white  blood  cell.  In  fact  the  two  are  quite  similar  bits  of  protoplasm 
manifesting  quite  similar  activities.  The  white  blood  cells  acquire  little  or 
no  resistance  to  it.  If  they  are  not  destroyed,  they  are  for  the  time  being 


MALARIA  119 

paralyzed  and  phagocytosis  suppressed.  We  previously  called  attention  to 
the  fact  that  10  grains  in  the  blood  of  a  patient  weighing  130  pounds  consti- 
tutes nearly  double  a  toxic  dose  for  the  phagocytes.  In  these  facts  lies  the 
explanation  of  the  failure  of  quinin  to  cure  chronic  cases.  The  parasite 
becomes  accustomed  to  the  poison  or  as  we  might  say,  acclimated  to  its 
unfavorable  environment,  while  the  white  blood  cells  succumb  to  the  toxic 
action.  The  parasite  has  then  nothing  to  oppose  its  action  and  it  multiplies 
and  thrives  at  the  expense  of  the  red  blood  cells.  The  latter  are  broken  up 
and  hemoglobinemia  and  hemoglobinuria  result.  This  breaking  up  is  increased 
by  the  action  of  the  quinin  itself  and  so  the  case  goes  on  from  bad  to  worse. 
In  fact,  it  is  claimed  by  many  southern  practitioners  that  blackwater  fever, 
the  hemoglobinuric  form  of  chronic  malaria,  is  due  to  quinin  and  not  to  the 
parasite. 

We  must  therefore,  in  these  cases,  abandon  the  use  of  quinin  and  search 
for  some  means  of  increasing  the  number  of  the  leucocytes  and  enhancing 
their  phagocytic  activity.  The  reaction  to  cold  applications  when  combined 
with  mechanical  means  is  that  which  best  produces  this  result.  Some 
enthusiastic  hydriatists  have  endeavored  to  combat  the  disease  by  the  use 
of  hot,  sweating  measures  applied  as  soon  as  there  are  any  indications  of 
the  beginning  of  the  chill  and  continued  until  sweating  is  well  established, 
little  attention  being  given  to  the  frequent  and  systematic  use  of  cold  fric- 
tions, affusions,  douches,  etc.  The  sweating  combats  nothing  but  the  effects 
of  the  chill;  it  in  no  way  removes  the  cause,  augments  the  vital  resistance, 
or  restores  the  blood  to  that  condition  in  which  it  is  best  able  to  combat 
infection.  On  the  contrary,  if  at  all  prolonged,  the  resistance  is  lessened. 
Quinin,  the  malarial  toxine,  and  long  hot  treatments,  all  lessen  the  number 
of  leucocytes,  driving  them  into  the  viscera  where  they  stagnate.  5 

Nearly  all  who  employ  hydrotherapy  in  any  regular  manner  have  witnessed 
the  beneficial  results  that  may  be  obtained  in  the  treatment  of  chronic  mal- 
aria. The  general  plan  to  be  followed  is  that  of  some  systematic  regime  of 
tonic  measures,  carefully  graduated  and  suited  to  the  needs  of  the  individ- 
ual case.  We  have  seen  chronic  cases,  in  which  30  grains  of  quinin  admin- 
istered daily  had  failed  to  check  the  fever,  brought  to  a  successful  issue  by 
the  regular  use  of  the  cold  mitten  friction  and  alternate  hot  and  cold  appli- 
cations. 

The  plan  followed  by  Fleury  in  the  treatment  of  over  100  cases  of  malaria 
in  the  German  colonies  in  Africa  is  worthy  of  imitation.  One  or  2  hours 
previous  to  the  expected  paroxysm,  he  administered  douches  at  55°  to  60°  F. 
From  his  experience  there,  he  concludes  that  in  chronic  cases  of  intermit- 
tent malarial  fever  with  cachexia,  anaemia,  relapses,  etc.,  cold  douches  are 
always  to  be  preferred  to  quinin,  also,  that  in  acute  intermittent  fever  it 
may  be  used  instead  of  quinin.  These  conclusions  were  confirmed  at  the 
military  hospital  at  Brussels  by  the  investigations  of  a  Royal  Belgian  Com- 
mission. Strasser,  Fisher,  Fodor  and  others,  have  reported  cases  success- 
fully treated  by  cold  applications.  H.  F.  Rand,  formerly  professor  of 
Physiologic  Therapeutics  in  the  University  of  Colorado,  has  successfully 

5  "In  the  first  attack  absolute  and  relative  leukopenia  is  observed  which  is  due  to  the  col- 
lection of  the  white  cells  in  the  liver  and  spleen,  to  the  destruction  of  the  phagocytes,  and,  in 
coachexia,  to  lesions  of  the  blood  making  organs." — Edward's  Practice  of  Medicine,  1907,  p.  118. 


120  THE  TREATMENT  OF  FEVERS 

treated  cases  by  the  use  of  the  cold  mitten  friction,  cold  towel  rub  and  the 
cold  half  bath  with  friction.  He  begins  a  number  of  hours  before  the  chill 
is  due.  He  reports  a  case  of  chronic  malaria  in  which  no  chill  appeared 
after  the  beginning  of  the  treatment.  At  the  end  of  a  week,  the  blood  was 
free  from  plasmodia. 

As  in  other  fevers,  the  rationale  of  these  measures  is  not  difficult  of 
explanation.  It  has  been  shown  by  Maragliano  6  that  contraction  of  the  sur- 
face vessels  in  malaria  begins  2  hours  before  the  temperature  begins  to  rise 
and  about  3  hours  before  the  paroxysm.  The  skin  vessels  continue  to  con- 
tract, and  the  fever  reaches  the  highest  point  when  the  vessels  are  in  a 
state  of  maximum  constriction.  During  the  sweating  stage  the  vessels 
dilate  and  when  maximum  dilatation  is  reached  the  temperature  returns  to 
normal.  During  the  2  hours  referred  to,  the  constriction  of  the  skin  vessels 
and  anemia  of  the  skin  becomes  well  "fixed,"  so  that  a  severe  prolonged 
chill  is  provided  for.  At  the  same  time,  there  is  an  enormous  retention  of 
heat  due  to  the  failure  in  heat  elimination.  The  internal  congestion  is 
intense.  Under  these  circumstances  the  cold  percussion  or  friction  has  a 
double  effect.  First,  by  the  production  of  circulatory  reaction  the  spasm 
of  the  peripheral  vessels  is  relieved  and  the  internal  congestion  gives  way 
because  of  an  equalization  of  the  circulation.  The  chill  is  thus  aborted. 
Second,  the  leucocytes  are  "mobilized"  and  phagocytosis  encouraged.  In 
malaria  the  leucocytes  forsake  the  peripheral  circulation  and  accumulate  in 
the  viscera,  especially  the  spleen.  Experiments  with  the  oncometer  show 
that  cold  applications  cause  contraction  of  this  organ.  This  action  together 
with  the  stimulation  of  the  vasomotors  of  the  peripheral  vessels  serves  to 
distribute  and  energize  this  vast  army  of  phagocytes. 

Hot  applications,  beginning  just  before  the  onset  of  the  chill,  would  serve 
to  dilate  the  peripheral  vessels  and  so  counteract  the  vasoconstriction  for 
the  time-being.  But  such  intense  and  prolonged  heat  has  no  tendency  to 
combat  the  cause,  i.  e.,  it  does  not  produce  mobilization  of  the  leucocytes 
nor  cause  them  to  destroy  the  parasites.  On  the  contrary  it  has  the  oppos- 
ite effect,  viz.,  the  causation  of  an  increase  in  the  visceral  stasis  of  leuco- 
cytes and  a  lessening  of  phagocytic  activity. 

Where  a  patient  reacts  poorly,  a  reaction  must  be  "compelled"  by  the 
use  of  local  hot  applications  simultaneously  with  the  cold.  This  is  for  the 
purpose  of  producing  a  sensation  of  warmth,  while  the  essential  effect — a 
brisk  activity  of  the  blood  vessels— is  secured  by  the  cold  application  accom- 
panied by  friction  or  percussion. 

The  following  suggestive  program  will  be  found  useful.  It  must  be 
varied  according  to  the  reactive  ability  of  the  patient.  Begin  the  first 
treatment  of  the  series  about  6  hours  before  the  expected  paroxysm  and 
follow  it  with  other  treatments  about  every  2  hours.  These  should  be  con- 
tinued until  the  time  for  the  chill  is  well  past. 

The  first  treatment  may  consist  of  an  enema  followed  by  a  hot  foot  bath 
and  two  fomentations  to  the  abdomen  of  brief  duration.  As  soon  as  the 
second  fomentation  has  been  placed,  begin  with  a  cold  mitten  friction.  This 
latter  should  be  given  with  very  cold  water  and  vigorous  friction.  Dry  the 

6     Plethysmograph  experiment — quoted  by  Buxbaum— Lehrbuch  der  Hydrotherapie,  1903. 


MEASLES  121 

patient  and  let  him  rest  for  an  hour  or  an  hour  and  a  quarter.  Next  administer 
quickly  alternate  hot  and  cold  to  the  spine,  followed  by  an  alternate  hot  and 
cold  percussion  douche  to  the  spine,  splenic  and  hepatic  areas,  and  the  legs.  If 
necessary  the  patient  may  stand  in  a  tub  of  hot  water  during  this  treatment 
or,  if  there  is  still  less  reactive  ability  manifest,  give  a  hot  shower  while 
the  cold  douche  is  being  administered.  Let  the  patient  drink  freely  of  water 
both  before  and  after  each  treatment.  The  third  treatment  may  consist  of 
a  cold  shallow  rubbing  bath  lasting  4  or  5  minutes  and  preceded,  if  necess- 
ary, by  a  hot  pail  pour  to  the  legs  and  lower  spine  only.  Two  attendants 
should  be  provided  to  administer  the  shallow  bath.  Succeeding  treatments 
should  be  carried  on  along  the  same  line.  These  may  be  the  cold  mitten 
friction  with  ice  water,  the  wet  sheet  rub,  the  percussion  douche,  the  salt 
glow  with  pail  pour,  etc. 

In  conclusion  we  can  not  do  better  than  quote  the  principles  given  by  Bux- 
baum: — " 

"The  best  water  treatment  for  malaria  consists  in  the  employment  of  a 
cold  application,  combined  with  powerful  thermic  stimulation.  The  form  of 
the  application  is  a  matter  of  indifference.  The  most  important  requirement, 
however,  is  the  production  of  a  good  reaction.  When  this  fails  to  take  place, 
success  will  be  wanting.  With  the  powerful  stimulating  procedure,  which 
may  be  chosen  according  to  personal  preference,  a  fan  douche  to  the  region 
of  the  spleen  may  serviceably  be  conjoined.  The  principal  objects  of  the 
therapeutist's  attention  are  the  proper  selection  of  the  time,  and  the  produc- 
tion of  a  good  reaction.  The  shorter  the  interval  between  the  procedure 
and  the  anticipated  chill,  the  more  certain  the  result.  With  regard  to  the 
procedures  to  be  employed,  they  consist  in  cold  vigorous  shower  baths;  a 
cold  rub  in  coarse  sheets  in  combination  with  sheet-baths;  cold  sitz-baths  of 
10  minutes'  duration;  cold  full  baths;  plunge  baths  and  other  suitable  meas- 
ures. The  treatment  should  be  continued  until  the  constitution  of  the  blood, 
the  digestion  and  circulation  are  restored  to  the  normal— briefly,  until  every 
sign  of  cachexia  has  disappeared. 

'  'According  to  Strasser,  the  effect  of  hydriatic  procedures  is  to  be  attributed 
to  the  fact  that  shortly  before  the  attack  the  infected  erythrocytes  disinte- 
grate under  the  influence  of  the  powerful  stimulation  of  the  cold,  so  that 
the  plasmodia  thus  set  free  are  destroyed  by  the  phagocytes." 


Measles  is  an  acute,  contagious,  febrile  disease  characterized  by  a  blotchy 
exanthem  and  accompanied  by  coryza.  It  is  usually  uneventful  in  its  course 
and  not  accompanied  by  any  great  mortality.  However,  the  patient  may  be 
made  much  more  comfortable  during  the  febrile  period,  and  the  vital  resist- 
ance so  sustained  that  there  is  less  tendency  to  bronchopneumonia.  The 
eruption  does  not  appear  until  the  fourth  day,  so  the  treatment  must  be 
begun  before  a  positive  diagnosis  can  be  made. 

In  this  disease,  as  well  as  in  scarlet  fever,  the  first  thing  to  be  accom- 
plished is  the  relieving  of  the  internal  congestion  occasioned  by  the  infect- 

7    Cohen's  System  of  Physiologic  Therapeutics,  Vol.  IX,  p.  136. 


122  THE  TREATMENT  OF  FEVERS 

ive  process.  If  the  case  is  untreated,  the  visceral  congestion  is  considerably 
lessened  on  the  appearance  of  the  eruption.  The  old  idea  that  measles  is 
much  more  serious  if  the  eruption  "strikes  in,"  or  does  not  appear  frankly, 
is  not  wholly  without  foundation.  At  the  time  the  eruption  makes  its  appear- 
ance the  skin  becomes  markedly  congested  and  this  serves  to,  at  least  par- 
tially, relieve  the  visceral  congestion.  A  treatment  which  most  efficiently 
relieves  the  internal  congestion  is  also  conducive  to  the  speedy  appearance 
of  the  rash.  In  our  practice,  we  have  seen  this  best  accomplished  by  means 
of  some  hot  sweating  treatment,  either  the  hot  pack  or  bath,  accompanied 
by  the  drinking  of  some  hot  liquid.  The  head  should  be  kept  cold  by  com- 
presses or  ice  bags.  In  some  cases,  where  there  is  not  much  chilliness, 
sweating  is  very  well  accomplished  by  the  use  of  the  wet  sheet  pack,  pro- 
longed to  the  sweating  stage.  This  draws  the  blood  from  the  viscera  and 
congests  the  skin.  At  the  termination  of  such  a  treatment,  the  case,  if  one 
of  measles,  will  show  the  characteristic  dull  red,  blotchy  eruption. 

Baruch  recommends  some  form  of  cold  treatment  for  the  same  purpose 
and  as  an  antipyretic  throughout  the  febrile  period.  He  prefers  the  gradu- 
ated bath,  or  a  warm  bath  in  which  the  patient  sits  while  cold  water  is 
poured  over  the  chest  and  shoulders.  The  full  expansion  of  the  lungs  occas- 
ioned by  such  treatment  aids  in  the  prevention  of  bronchopneumonia.  Be- 
cause of  the  irritibility  of  the  skin,  it  is  not  best  to  employ  friction  during 
the  cold  bath.  Cold  affusions  to  the  head  and  back  of  the  neck  are  useful 
in  relieving  stupor,  delirium  and  other  cerebral  symptoms.  We  have  found 
the  wet  sheet  pack,  frequently  renewed  by  sprinkling  cold  water  over  it, 
an  excellent  means  of  reducing  the  temperature  and,  at  the  same  time,  it 
provides  against  chilliness,  since  between  each  renewal  of  the  pack,  it 
warms  up  and  reaction  is  completed.  This  may  be  repeated  until  the  tem- 
perature has  been  reduced  to  101°  F.,  or  even  less.  The  evaporating  stage 
of  the  pack  should  last  for  a  greater  length  of  time  than  the  heating  stage, 
so  that  the  total  effect  will  be  that  of  heat  abstraction. 

Bronchopneumonia.  Capillary  bronchitis  is  the  most  serious  and  fatal  of 
the  complications  arising  during  the  course  of  measles.  In  this  disease, 
there  is  a  special  tendency  to  congestion  of  the  mucous  membranes  of  the 
respiratory  tract,  as  evidenced  by  the  coryza  which  invariably  accompanies 
it.  The  condition  of  the  lungs  may  prove  to  be  of  a  tubercular  nature;  this 
is  not  an  infrequent  sequel  and  one  accompanied  by  a  high  mortality.  In 
the  treatment  of  bronchopneumonia,  complicating  measles,  we  employ  the 
same  methods  used  in  the  treatment  of  this  disease  when  occurring  alone. 
The  child  should  be  placed,  at  intervals  of  about  3  hours,  in  a  bath  at  90°  to 
95  .  When  sufficiently  warm,  let  the  child  sit  upright  and  cold  affusions  be 
applied  to  the  chest,  shoulders  and  back.  The  water  for  the  affusion  may 
be  at  a  temperature  of  from  70°  to  75°.  This  vigorous  means  provokes  an 
unusually  deep  inspiration,  which  is  followed  for  a  considerable  time,  by 
slower  respirations  of  greater  depth.  It  facilitates  the  expulsion  of  mucus. 

Another  treatment  that  has  given  excellent  success  is  the  cold  compress 
applied  to  the  chest.  This  should  be  wrung  from  very  cold  water,  applied 
quickly  over  the  entire  upper  chest,  allowed  to  remain  for  a  very  short  time, 
and  then  renewed.  This  may  be  repeated  from  two  to  four  times,  the  last 


SCARLET  FEVER  123 

compress  used  being  allowed  to  remain  for  30  to  60  minutes.  The  chest  may 
be  slapped  in  rapid  succession  with  cold  wet  towels.  This,  of  course,  should 
not  be  done  if  the  temperature  is  very  high.  In  the  latter  case,  the  evap- 
orating wet  sheet  pack  provides  for  the  reduction  of  the  fever  and  serves 
to  stimulate  respiration.  Gaseous  interchange  and  oxygenation  of  the  blood 
are  greatly  promoted,  the  circulation  is  increased  and  the  heart  strength- 
ened. 

Among  other  measures  that  may  be  used  to  good  advantage  are  cold  spong- 
ing, hot  sponging  and  the  cold  towel  rub. 


Scarlet  Fever 

Scarlatina  is  an  acute,  contagious  fever  characterized  by  a  diffuse  scarlet 
erythema  accompanied  by  sore  throat  or  tonsillitis.  It  has  a  higher  mortal- 
ity than  measles  and  is  accompanied  by  more  serious  complications.  In 
scarlet  fever,  as  in  all  other  febrile  diseases,  the  chief  objects  to  be  attained 
by  treatment  are  the  maintaining  of  the  vital  resistance,  increasing  phago- 
cytosis in  order  to  combat  the  infection,  sustaining  the  heart  and  circulation, 
and  controlling  the  nervous  manifestations  by  tonic  measures.  Before  the 
appearance  of  the  eruption,  scarlet  fever  should  be  treated  in  precisely  the 
same  manner  as  measles.  Usually  by  the  time  the  physician  is  called,  the 
eruption  has  already  begun  to  make  its  appearance  and  here,  as  in  measles, 
we  have  found  the  use  of  the  initial  hot  bath  or  pack  most  effectual  in  pro- 
moting a  decided  and  general  eruption.  As  soon  as  its  appearance,  or  other 
symptoms  give  evidence  that  the  internal  congestion  has  been  materially 
relieved,  some  form  of  cold  treatment  should  immediately  follow.  Because 
of  the  sore  throat  and  tonsillitis,  it  may  be  necessary  to  precede  the  general 
hot  treatment  by  fomentations  to  the  neck  and  upper  chest.  Cold  compres- 
ses or  ice  bags  should  be  applied  to  the  head  at  the  same  time,  and  the  treat- 
ment accompanied  by  a  hot  foot  bath  or  leg  pack.  These  partial  hot  appli- 
cations in  themselves,  may  produce  general  perspiration,  in  which  case,  it  is 
unneccessary  to  use  other  hot  treatment.  A  full,  hot  bath  may  be  service- 
able in  place  of  the  hot  pack  and  when  the  patient  has  become  thoroughly 
warmed,  the  succeeding  cold  treatment  may  be  applied  by  proper  graduation 
of  the  bath.  The  temperature  must  not  be  reduced  too  far,  since  it  is 
impossible  to  employ  friction  on  account  of  the  rash. 

The  wet  sheet  pack,  kept  at  the  evaporating  stage  and  frequently  renewed, 
is  a  very  efficient  means  of  reducing  the  temperature,  energizing  the  nerves 
and  circulation.  After  the  eruption  has  once  appeared,  there  need  be  no 
fear  of  "driving  the  rash  in."  However,  it  is  necessary  to  produce  a  de- 
cided cutaneous  reaction  with  every  cold  treatment  used.  The  extreme  cold 
bath  is  counterindicated.  Affusions  and  ablutions,  beginning  with  water  at 
90°,  gradually  lowering  the  temperature  until  water  at  70°  or  75°  is  used, 
are  also  useful  in  controlling  the  temperature  and  assisting  the  heart's 
action. 

It  is  necessary  that  the  patient  drink  a  considerable  quantity  of  water  to 
provide  for  thorough  elimination,  because  of  the  tendency  to  renal  conges- 
tion and  nephritis.  This  latter  condition  is  the  most  important  complication 
of  scarlet  fever. 


124  THE  TREATMENT  OF  FEVERS 

Nephritis.  Should  this  condition  appear  during  the  febrile  period,  it  is 
not  necessary  to  stop  all  cold  treatments,  but  the  temperature  should  be 
somewhat  moderated  and  the  time  shortened.  Short  hot  applications  may 
be  made  so  as  to  enhance  the  reactive  ability,  and  these  immediately  followed 
by  such  measures  as  cold  affusions,  cold  sponging,  wet  sheet  pack  or  the 
graduated  bath.  In  the  case  of  the  graduated  bath,  the  initial  heating  may 
be  accomplished  by  beginning  the  bath  at  95°  to  98°,  raising  the  temperature 
a  few  degrees  until  the  patient  is  well  warmed,  and  then  gradually"  cooling 
the  bath  to  80°  or  85°.  Chilliness  should  not  result  from  any  treatment,  as 
this  tends  to  increase  the  renal  congestion. 

If  the  wet  sheet  pack  is  used,  the  sheet  may  be  wrung  from  hot  water 
and  then  maintained  at  the  evaporating  stage  and  renewed  by  sprinkling 
cold  water  over  the  sheet.  During  all  this  time,  the  drinking  of  large 
quantities  of  water  should  be  encouraged.  If  the  nephritis  should  make  its 
first  appearance  after,  or  at  the  close  of,  the  febrile  period,  it  is  perhaps 
best  to  employ  the  means  commonly  used  in  treating  nephritis,  that  is,  dia- 
phoretic measures.  The  hot  bath  with  ice  to  the  head  and  heart,  the  hot 
blanket  pack  or  partial  hot  applications,  such  as  the  hot  foot  bath  accom- 
panied by  fomentations  to  the  spine,  chest  or  abdomen,  are  all  useful  in  pro- 
ducing sweating.  If  the  hot  blanket  pack  is  used,  it  may  be  very  conven- 
iently followed  by  the  wet  sheet  pack,  wrung  from  water  at  75°  and 
continued  to  the  sweating  stage.  Reaction  should  ensue  promptly.  The 
child  may  be  left  in  this  pack  an  hour  or  two,  or  until  the  sheet  is  nearly  dry. 

The  cold  towel  rub  and  cold  mitten  friction  may  be  used  to  promote  cir- 
culatory reaction,  providing  desquamation  has  well  begun.  It  is  best  not  to 
employ  the  cold  mitten  friction,  should  the  nephritis  occur  before  the  erup- 
tion subsides.  Under  these  treatments,  the  albumen  gradually  lessens  and 
casts  disappear  from  the  urine.  Should  there  be  oedema  about  the  feet  and 
ankles,  the  alternate  hot  and  cold  foot  or  leg  bath  should  be  used  and  fol- 
lowed by  centripedal  massage.  To  aid  desquamation  and  prevent  spreading 
of  the  contagion,  the  cold  mitten  friction  or  salt  glow  may  be  used  to  hasten 
the  removal  of  the  scales.  Either  treatment  should  be  followed  by  an  oil 
rub  to  prevent  further  rubbing  off  of  the  contagion-carrying  epithelium. 

Endocarditis.  Should  this  complication  arise,  all  cold  tub  baths  should 
be  discontinued,  also  cold  affusions.  The  patient  must  be  kept  at  absolute 
rest,  with  the  ice  bag  to  the  heart  intermittently.  After  the  eruption  has 
disappeared,  there  is  no  measure  equal  to  the  cold  mitten  friction  in  assist- 
ing the  circulation  and  relieving  the  heart.  For  further  treatment,  see 
"Endocarditis." 


La  Grippe — Influenza 

The  clinical  condition  in  influenza  is  quite  different  from  that  of  typhoid 
fever.  In  this  disease,  the  fever  is  of  the  short,  high  type,  with  rapid  pulse 
and  high  blood  pressure.  These  are  the  manifestations  that  are  found 
among  young  adults.  With  older  persons,  the  disease  is  quite  likely  to  be 
accompanied  by  considerable  asthenia,  the  digestive  system  and  the  nervous 


INFLUENZA  125 

system  bearing  the  brunt  of  the  infective  process.     With  younger  persons, 
the  respiratory  tract  is  more  likely  to  be  affected. 

Since  this  is  a  short  sthenic  fever,  the  treatment  employed  will  differ  con- 
siderably from  that  used  in  typhoid  fever.  Aside  from  cold  applications  to 
the  head,  it  is  unnecessary  to  employ  long  cold  treatments  for  the  purpose 
of  reducing  the  fever  and  all  generalized  cold  applications  are  counterindi- 
cated.  With  an  individual  that  has  been  previously  strong  and  well  and  is 
in  good  flesh,  it  may  be  possible  to  treat  the  case  from  the  start  by  vigor- 
ous cold  applications  with  friction.  This  enhances  the  vital  resistance, 
increases  leucocytosis  and  so  combats  the  infection  in  a  very  direct  manner. 

With  cases  as  they  usually  present  themselves,  we  have  obtained  the  best 
results  by  the  use  of  an  initial  sweating  treatment  such,  for  example,  as 
the  hot  leg  bath  accompanied  by  fomentations  to  the  spine  or  to  the  chest 
and  throat,  with  cold  compresses  to  the  head  and  neck.  At  the  same  time, 
the  patient  should  drink  several  glasses  of  hot  lemonade.  Chilliness  is  soon 
overcome  and  the  patient  begins  to  perspire  profusely.  As  soon  as  profuse 
perspiration  is  well  established,  the  patient  may  be  given  a  graduated 
shower  beginning  at  106°  to  108°,  gradually  increasing  the  temperature  to 
the  limit  of  toleration.  While  in  the  hot  spray,  the  patient  should  wear  a 
cold  compress  to  the  head.  As  seon  as  he  is  again  well  warmed,  the  tem- 
perature should  very  gradually  be  reduced  to  90°.  This  abstracts  much  of 
the  heat  that  has  been  communicated  to  the  body  by  the  sweating  treat- 
ment. The  patient  should  now  be  put  to  bed,  with  hot  water  bottles  to  the 
feet  and  allowed  to  perspire  gently  for  a  number  of  hours. 

Great  care  must  be  taken  that  the  patient  is  not  overheated  by  the  sweat- 
ing treatment,  since  fainting  is  quite  likely  to  result  unless  the  cold  com- 
presses to  the  head  and  neck  are  frequently  renewed.  In  some  cases,  it  is 
necessary  that  the  patient  be  in  the  recumbent  position  while  taking  the 
treatment  and,  for  this  reason,  the  horizontal  electric  light  cabinet  is  very 
serviceable  in  securing  free  diaphoresis. 

In  case  this  treatment  has  been  carried  out  in  the  evening,  on  the  follow- 
ing morning  the  patient  should  be  treated  by  preliminary  hot  applications 
for  the  purpose  of  relieving  the  aching  of  the  back  and  limbs.  This  is  best 
accomplished  by  the  leg  pack  or  large  fomentations  to  the  spine.  They 
should  not  be  continued  long  and  should  be  followed  immediately  by  a  vigorous 
cold  mitten  friction.  From  this  point  on,  it  is  best  to  treat  the  case  as  far 
as  possible  with  tonic  measures,  such  as  the  cold  mitten  friction,  cold  towel 
rub,  or  the  hot  and  cold  douche  to  the  spine  and  legs,  finishing  with  the 
alternating  douche  to  the  feet.  The  sweating  treatment  should  not  be 
repeated  unless  it  seems  quite  necessary. 

Any  plan  of  treatment  may  fail  of  its  best  results  in  case  the  bowel  is  not 
thoroughly  unloaded  at  the  beginning.  This  may  be  best  accomplished  by 
thorough  enemata.  Special  complications  require  attention  outside  of  the 
general  plan  of  treating  influenza.  Bronchitis  and  cough,  with  pain  in  the 
chest,  should  be  treated  by  large  fomentations,  followed  by  the  heating 
chest  pack.  Pharyngitis  or  tonsillitis  should  be  treated  in  the  same  manner, 
that  is,  with  fomentations,  and  a  cold  heating  compress  applied  between 


126  THE  TREATMENT  OF  FEVERS 

treatments.  The  nervous  symptoms  are  best  met  by  the  ice  cap,  or  cold 
compresses  to  the  head.  The  pain  may  be  very  materially  relieved  by  the 
use  of  very  hot  fomentations.  In  all  cases,  however,  the  treatment  should 
be  concluded  with  a  vigorous  cold  mitten  friction.  It  is  not  designed  that 
the  cold  frictions  shall  materially  lower  the  temperature  in  and  of  themselves, 
that  is,  the  fall  in  temperature  does  not  result  immediately  after  the  appli- 
cation, but  rather  succeeds  in  a  few  hours.  If  the  temperature  is  very  high, 
it  may  be  effectually  combated  by  the  use  of  the  ice  bag  to  the  heart,  with 
ice  applications  to  the  head.  Both  should  be  continued  with  but  little  inter- 
ruption. 

The  asthenic  type  of  influenza,  except  in  old  people  or  chronic  invalids,  is 
not  now  as  common  as  during  the  pandemic  of  1889  and  the  years  immedi- 
ately following.  In  the  event  of  severe  asthenia  the  treatment  is  to  be 
carried  on  along  general  lines  with  special  reference  to  those  measures 
which  will  sustain  the  heart  and  circulation.  The  treatment  of  respiratory 
or  digestive  complications  demand  special  care  and  is  to  be  carried  on  along 
lines  laid  down  elsewhere. 


CHAPTER    XVIII 
INFLAMMATION  AND  ANTIPHLOGISTIC  EFFECTS 


Before  considering  the  conditions  present  in  inflammations  and  their  treat- 
ment, it  will  be  well  to  understand  the  principles  involved  in  the  production 
of  certain  circulatory  effects  which  are  much  used  in  the  treatment  of  inflam- 
mations. We  shall  therefore  first  turn  our  attention  to  the  methods  and 
principles  concerned  in  the  production  of  derivation  and  fluxion. 

Derivation  is  the  withdrawing  of  blood  from  an  organ  or  part  of  the  body 
by  increasing  the  amount  of  blood  in  some  other  part.  Practically,  it  is  the 
reduction  of  congestion  (and  inflammation)  by  drawing  the  blood  from  the 
part  congested  into  some  other  part. 

Fluxion  consists  in  increasing  the  rapidity  of  the  blood  current  in  a  par- 
ticular part,  and  consequently,  the  total  amount  of  blood  passing  through 
that  part  in  a  given  time.  It  is  the  production  of  arterial  hyperemia. 

Derivation — Depletion 

In  derivation,  there  is  produced  a  collateral  hyperemia  with  local  anemia. 
This  is  most  effectually  secured  by  the  simultaneous  application  of  both  heat 
and  cold  in  the  following  manner  (Plate  3) :  A  large,  very  hot  application 
is  made  to  a  distant  part;  in  many  cases,  it  extends  up  to  and  includes  the 
congested  part.  At  the  same  time,  an  ice  bag,  ice  pack  or  ice  compress  is 
placed  directly  over  the  inflamed  organ.  In  this  way,  collateral  hyperemia 
is  secured  and  local  anemia  re-enforced  by  the  direct  or  reflex  vasoconstrict- 
ing  influence  of  the  ice.  The  local  anemia  is  made  extreme  by  both  a  '  'push ' ' 
and  a  "pull"  effect  on  the  circulation,  the  "pull"  being  secured  by  the  vis 
a  fronte  of  the  hot  application,  and  the  "push"  by  the  vis  a>  tergo  of  the 
reflex  contraction  of  the  blood  vessels,  due  to  the  cold  application  over  the 
part.  The  most  effective  derivation  is  secured  by  direct  contact  of  the  body 
with  hot  water.  A  hot  leg  bath  is  more  effective  than  a  hot  leg  pack,  and 
a  hot  leg  pack  with  the  wet  blanket  applied  directly  to  the  skin  is  more 
effective  than  when  a  dry  blanket  intervenes. 

The  following  are  the  principal  derivative  measures  indicated  in  the  acute 
stage  of  the  diseases  mentioned: — 

1.  APPENDICITIS.     Hot  hip  and  leg  pack,  with  ice  bag  over  the  appendix. 

2.  PERITONITIS.     Hot  hip  and  leg  pack,  or  leg  pack  only,  with  ice  com- 
press to  abdomen. 

3.  PUERPERAL   INFECTION   AND  ACUTE   SALPINGITIS.    Full  hot  blanket 
pack,  or  hip  and  leg  pack,  with  ice  to  the  pelvis. 

4.  PNEUMONIA.     Hot  leg  bath,  hip  and  leg  pack,  or  full  blanket  pack, 
with  cracked  ice  compress  over  the  lobe  affected. 

5.  MENINGITIS.     Hot  leg  pack,  with  ice  cravat,  ice  cap  and  ice  bag  to 
the  base  of  the  brain  and  the  upper  spine. 


128  INFLAMMATION  AND  ANTIPHLOGISTIC  EFFECTS 

6.  MASTOIDITIS.     Hot  leg  bath,  with  ice  cravat  or  ice  bag  over  cartoid 
artery,  ice  cap  and  fomentations  to  the  mastoid. 

7.  ALVEOLAR  ABSCESS.     Same  as  above,  except  fomentations  to  the  jaw. 

8.  OSTEOMYELITIS  (of  Tibia).     Fomentations  to  leg  or  leg  pack  with  ice 
over  the  femoral  artery. 

9.  CEREBRAL  CONGESTION.     Hot  leg  bath,  with  ice  cravat,  ice   cap  or 
cold  compress  to  the  entire  face  and  cranium. 

10.     RENAL  CONGESTION.     Fomentations  to  back.     Hot  trunk  pack  or  full 
blanket  pack,  with  ice  bag  to  the  lower  third  of  sternum. 

Precautions:  In  order  to  maintain  collateral  hyperemia,  the  treatment 
must  be  concluded  with  such  a  vigorous  tonic  measure  as  a  cold  mitten  fric- 
tion, applied  to  the  part  previously  covered  by  the  hot  application.  The  hot 
application  alone  produces  passive  dilatation  of  the  blood  vessels.  If  the 
treatment  is  stopped  here,  the  circulation  will  soon  equalize  itself  or  even  a 
worse  internal  congestion  may  occur.  The  cold  mitten  friction,  however, 
produces  an  active  dilatation  (alternate  dilatation  and  contraction)  of  the 
blood  vessels,  thus  maintaining  for  a  longer  time,  the  derivation  secured  by 
the  hot. 

Derivation  by  Hot  Alone.  It  some  cases,  sufficient  blood  can  be  with- 
drawn from  a  part  by  applying  heat  over  the  cutaneous  branches  coming 
from  the  artery  supplying  the  deeper  congested  part  or  organ.  In  this  case, 
the  larger  flow  of  blood  is  diverted  into  the  cutaneous  (and  superficial) 
branches,  leaving  less  to  pass  to  the  deeper  branches.  Examples  of  this  are 
found  in  the  treatment  of, — 

1.  PLEURISY.     Large  fomentations  to  the  chest  divert  the  blood  flowing 
in  the  intercostal  and  internal  mammary  arteries  from  the  pleural  branches 
to  the  posterior,  lateral  and  anterior  cutaneous  branches. 

2.  RENAL  CONGESTION.     Large  fomentations  over  the  lower  dorsal  and 
lumbar  spine  the  entire  width  of  the  back.     This  diverts  the  blood  from  the 
renal  arteries  to  the  lower  intercostal  and  lateral  lumbar  branches  of  the 
aorta. 

3.  SIMPLE  SPINAL  CONGESTION.     Large  fomentations  to  the  spine  divert 
the  blood  from  the  spinal  arteries  to  the  posterior  cutaneous  arteries  supply- 
ing the  skin  and  muscles  of  the  back. 

4.  CONGESTIVE  SCIATICA.     Large  fomentations  to  back  and  side  of  thigh 
divert  the  blood  from  the  nerve  to  the  skin. 

5.  TRIGEMINAL   NEURALGIA.      Fomentations   to  side  of  face  divert  the 
blood  to  the  skin.     This  may  be  re-enforced  by  the  use  of  an  ice  bag  over 
the  carotid,  thus  mechanically  lessening  the  total  volume  of  blood  going  to 
the  head. 

Precautions:  In  pleurisy  and  neuralgia,  cold  increases  the  pain,  hence  can 
not  be  used. 

Fluxion 

When  hot  and  cold  applications  are  used  to  secure  derivation,  they  are 
used  simultaneously  and  to  different  areas.  If  the  hot  and  cold  are  used 
alternately  and  to  the  same  area,  the  result  is  fluxion.  This  may  be  either 
by  direct  effect  in  the  part  treated,  or  by  reflex  action  in  another  part. 
This  effect  is  intensified  by  friction  or  percussion. 


FLUXION  129 

All  alternately  applied  hot  and  cold  applications  are  tonic,  both  locally  and 
generally.  We  may  here,  for  the  sake  of  clearness  and  brevity,  confine 
ourselves  to  the  consideration  of  measures  desired  to  produce  chiefly  violent 
circulatory  reaction  in  a  given  part  or  organ. 

The  following  are  the  principal  means  used  to  produce  fluxion: — 

1.  Alternate  hot  and  cold,  using  fomentations  and  ice,  or  fomentations 
and  cold  compresses  (revulsive  compress). 

2.  Alternate  hot  and  cold  douches  or  sprays,  as  to  spine,  legs,  liver,  etc. 

3.  Alternate  hot  and  cold  packs. 

4.  Alternate  hot  and  cold,  as  to  head  or  kidneys  and  sternum. 

5.  Revulsive  or  alternate  hot  and  cold  sitz  bath. 

6.  Alternate  hot  and  cold  foot  or  leg  bath. 

7.  Alternate  hot  and  cold  immersion,  as  of  hand  and  arm. 

8.  Alternate  hot  and  cold  vaginal  douche,  rectal  irrigation,  etc. 

In  all  the  above  measures,  the  condition  produced  is  that  of  active 
(arterial)  hyperemia.  The  alternate  dilatation  and  contraction  of  the 
blood  vessels  is  stimulated.  This  condition  is  known  as  active  dilatation. 
These  alternating  changes  of  vasoconstriction  and  vasodilatation  are  more 
rapid  and  extreme  than  the  normal.  They  very  markedly  increase  the 
number  of  white  blood  cells  in  a  given  part,  and  consequently  the  resulting 
phagocytosis.  It  is  this  which  makes  it  especially  valuable,  and  almost  in- 
dispensable in  some  acute  congestions  and  inflammations,  such  as  an  acute 
infection  of  a  hand  or  a  foot,  where  lymphangitis  and  lymphadenitis  are 
likely  to  follow  so  quickly. 

Perhaps  the  largest  field  for  the  use  of  fluxion  (arterial  hyperemia)  is  in 
chronic  congestions,  whether  a  sequel  to  chronic  infections  or  non-inflam- 
matory. In  these  cases  the  congestion  is  of  a  passive  type,  i.  e.,  venous 
stasis.  The  treatment  is  also  indicated  in  local  anemias. 

Below  are  given  some  of  the  more  important  indications  for  the  use  of 
fluxion: — 

1.  Acute  infections,  as  of  hand,  arm  or  foot. 

2.  Convalescence  from  all  infections  (stage  of  passive  or  venous  conges- 
tion). 

3.  Chronic  congestion  of  liver. 

4.  Chronic  pelvic  congestion,  as  of  uterus  or  adnexa,  whether  simple  or 
following  infections. 

5.  Uterine  subinvolution. 

6.  Amenorrhea. 

7.  Myelitis  (chronic  stage). 

8.  Locomotor    ataxia    and   other    paralyses    of  spinal  origin  (in  chronic 
stage) . 

9.  Alcoholic  neuritis  (after  acute  stage). 

10.  Muscular  atrophies. 

11.  Tubercular  arthritis  and  synovitis. 

12.  Chronic  osteomyelitis. 

13.  Varicose  ulcer. 

Precautions:  In  acute  infections,  massage  effects,  such  as  friction  or 
percussion,  should  be  avoided.  Dire  effects  in  the  quick  spread  of  the  bac- 
teria to  other  parts,  will  result  if  these  are  used. 


130         INFLAMMATION  AND  ANTIPHLOGISTIC  EFFECTS 

Revulsion.  According  to  Borland,  this  term  is  synonomous  with  deriva- 
tion and  depletion.  Kellogg  evidently  uses  it  to  designate  the  mode  of  giv- 
ing a  hot  and  cold  application,  the  chief  effect  of  which  is  fluxion.  For 
example,  a  revulsive  compress — a  treatment  consisting  of  a  single  hot  appli- 
cation, followed  by  a  single  cold  application. 

Again,  it  is  used  to  designate  derivation  secured  by  collateral  fluxion,  as 
in  the  use  of  hot  and  cold  foot  or  leg  bath,  or  a  hot  and  cold  percussion  douche 
to  the  feet  and  legs  to  relieve  cerebral  congestion.  When  hot  and  cold  are 
alternately  applied  to  one  part  of  the  body,  thus  producing  fluxion  in  that 
part,  it  will  withdraw  more  or  less  blood  from  other  related  or  distant  parts. 
This  diverse  application  of  the  term  has  led  to  no  little  confusion.  While 
the  term  can  not  be  fully  dispensed  with,  the  student  should  bear  in  mind 
that  the  effect  is  that  of  either  derivation  or  fluxion. 

Pathogenesis  of  Inflammation 

"Inflammation  consists  of  the  series  of  changes  constituting  the  local  mani- 
festation of  the  attempt  at  repair  of  actual  or  referred  injury  to  a  part,  or 
briefly,  it  is  the  local  attempt  at  repair  of  actual  or  referred  injury.  Inflam- 
mation is  the  reaction  of  irritated  and  damaged  tissues  which  still  retain 
vitality."  l 

The  pathologic  conditions  in  an  inflammatory  process  may  be  partially 
understood  by  the  five  cardinal  symptoms,  viz., — 

1.  Rubor — redness. 

2.  Tumor — swelling. 

3.  Calor— heat. 

4.  Dolor — pain. 

5.  Functio  Iffisa— loss  of  function. 

The  primary  cause  of  the  inflammation,  whatever  it  may  be,  is  respons- 
ible for  these  conditions,  which  are  largely  circulatory  disturbances.  The 
condition  in  the  acute  stage  is  one  of  (1)  arterial  hyperemia  with  (2)  a  serous 
exudate,  and  (3)  an  increasing  number  of  leucocytes  in  the  blood  stream  and 
tissues;  from  the  latter,  they  return  to  the  blood  stream  less  rapidly  than 
normal.  (4)  The  inflamed  part  is  bright  red.  (5)  The  pain  is  severe  and 
often  throbbing  in  character  because  of  the  increasing  tension  on  the  nerves 
caused  by  the  swelling.  2 

In  the  chronic  stage,  the  condition  is  one  of  (1)  venous  congestion  (passive 
hyperemia) .  (2)  There  is  a  beginning  organization  of  the  exudate,  and  (3) 
a  dearth  of  leucocytes.  (4)  The  part  is  of  a  dark  red  or  bluish  color.  (5) 
The  pain  is  less  severe,  and  described  as  dull  and  heavy  in  character. 

In  the  intermediate  stages,  the  inflammatory  process  passes  gradually 
from  the  first  to  the  last  condition.  The  circulation  begins  to  be  slowed, 
and  more  and  more  blood  accumulates  in  the  capillaries  and  veins,  less  arter- 
ial blood  being  present,  so  that  the  total  amount  of  blood  in  the  organ  is 
increased  above  normal.  The  severe  or  throbbing  pain  gives  way  to  the 
more  constant,  but  less  severe,  dull  pain.  The  leucocytes  find  their  way 
back  into  the  circulation  (lymphatic  or  blood)  if  no  suppuration  occurs,  and 
the  number  in  the  tissue  decreases. 

1  Adami — Inflammation,  pp.  5,  227. 

2  For  the  details  of  the  process  see,  Adami — Inflammation,  pp.  34-36. 


PRINCIPLES  OF  TREATMENT  131 

• 

Principles  of  Treatment 

In  the  Acute  Stage.  (1)  Limit  the  congestion,  (2)  hasten  absorption  of 
the  exudate  and  prevent  f  uther  exudation,  (3)  energize  and  assist  the  phago- 
cytes in  combating  the  infection  or  noxious  agent,  (4)  relieve  the  pain. 
While  inflammation  is  a  protective  process,  it  must  not  be  supposed  that  it 
is  always  well  regulated,  or  able,  unassisted  to  cope  with  the  disturbing 
cause. 

The  serous  exudate  of  this  stage  consists  of  a  more  concentrate  lymph 
than  normal,  i.  e.,  a  lymph  containing  more  proteins,  which  doubtless  serve 
for  the  nutrition  of  the  cells  necessary  in  the  regeneration  of  tissue  which 
follows. 3  It  is  necessary  only  to  limit  this  to  a  proper  amount  and  hasten 
its  return  to  the  blood  and  lymph  vessels  when  its  work  is  done.  This  means 
the  restoration  of  the  proper  rate  of  exudation  and  absorption  and  is  applic- 
able to  the  leucocytes  as  well  as  the  fluids. 

In  the  Chronic  Stage.  (1)  Stimulate  and  quicken  the  circulation  by  the 
production  of  arterial  hyperemia,  and  (2)  stimulate  the  process  of  phagocy- 
tosis, thus  (3)  promoting  resolution  and  absorption  of  the  exudate  and 
thereby  preventing  its  organization. 

In  the  acute  stage  of  an  inflammation,  i.  e.,  during  the  first  few  hours  or 
first  day  or  two,  extreme  cold  should  be  used  over  the  part  continuously,  or 
with  only  short  intermissions,  in  order  to  lessen  the  congestion,  relieve  the 
pain,  and,  if  possible,  thereby  abort  the  inflammation.  In  many  cases  it  is 
necessary  to  re-enforce  the  continuous  cold  by  hot  applications  to  collateral 
areas  (derivation)  in  order  to  effectually  reduce  the  congestion.  The  cold 
energizes  the  white  blood  cells,  increasing  their  number  and  efficiency  in 
the  destruction  of  bacteria,  and  hastens  their  return  to  the  blood  stream. 

After  the  acute  stage  has  passed,  i.  e.,  at  the  end  of  a  few  hours,  or  on 
the  second  day,  the  cold  applications  should  be  replaced  by  a  heating  com- 
press; or,  if  cold  compresses  were  used  in  the  first  stage,  it  is  only  neces- 
sary to  leave  them  on,  thus  making  a  heating  compress.  These  cold  and 
heating  compresses  should  be  replaced  at  intervals  of  1  to  3  hours,  using 
short  fomentations  when  the  change  is  made. 

As  the  inflammation  progresses  toward  the  chronic  stage,  more  heat  and 
less  cold  should  be  used.  After  the  acuteness  of  the  inflammation  has 
entirely  subsided,  the  most  vigorous  hot  and  cold  applications  should  be  used 
in  order  to  lessen  venous  stasis  and  bring  to  the  organ  a  greater  supply  of 
fresh  blood  (fluxion),  for  the  time  producing  an  arterial  hyperemia.  It  is 
possible  to  use  fluxion  even  immediately  following  the  first  few  hours  of 
some  inflammations,  provided  they  are  not  in  a  dangerous  area,  i.  e.,  where 
rupture  would  prove  fatal  or  produce  serious  complications. 

It  has  been  shown  that  in  some  cases  the  maintenance  of  a  high  external 
temperature  is  conducive  to  a  more  rapid  and  benign  course  of  the  inflam- 
mation than  where  cold  is  used.  These  are  doubtless  cases  of  inadequate  reac- 
tion as  suggested  by  Adami, 4  better  results  being  due  to  the  increased  amount 
of  blood  brought  to  the  part.  In  the  majority  of  cases  still  greater  benefit 

3  Starling — Fluids  of  the  Body,  p.  174. 

4  Inflammation,  pp.  199,  218. 


132         INFLAMMATION  AND  ANTIPHLOGISTIC  EFFECTS 

• 

results  from  the  use  of  alternate  hot  and  cold  applications,  since  these  pro- 
duce an  arterial  hyperemia  which  has  no  after  tendency  to  stasis. 

The  stage  of  the  inflammation  may  best  be  judged  by  the  color.  A  bright 
red  color  is  evidence  of  an  acute  process  and  a  dull  red,  dusky  or  bluish 
color,  of  a  chronic  process.  Inflammations  in  certain  localities  should  be 
treated  by  hot  alone,  until  after  the  first  stage  is  passed.  This  is  true  of 
pleurisy. 

"For  antiphlogistic  purposes,  it  may  be  safely  held  that  in  the  early  stage 
of  congestion,  cold  applications  are  useful  so  long  as  the  circulation  in  the 
affected  part  is  still  open,  which  is  indicated  by  the  turgor.  But  when  the 
parts  assume  a  cyanotic  hue,  when  leucocytes  have  begun  to  adhere  in  large 
numbers  to  the  vessel  wall  and  emigration  has  become  active,  applications 
of  warmth  further  the  latter  and  hasten  suppuration  when  it  is  unavoidable. 
The  cold  compress  diminishes  congestion,  retards  leucocytosis  and  emigra- 
tion of  white  cells,  while  the  warm  applications  have  the  contrary  effect, 
each  being  most  useful  in  the  respective  stage  of  inflammation. 

"The  antiphlogistic  effects  of  cold  compresses  are  readily  explained  by 
the  results  of  Genzmer's  experiments  upon  local  blood  letting.  He  came  to 
the  conclusion  that  the  favorable  effect  of  bleeding  upon  the  inflamed  parts 
beneath  was  ascribable,  not  to  their  becoming  more  anemic,  but  to  the  fact 
that  the  blood  stream  became  more  rapid,  and  thus  the  corpuscles  which 
had  adhered  to  the  vessel  walls  were  loosened  and  driven  into  the  general 
circulation.  The  fluxion  therefore,  which  the  application  of  cold  or  warm 
compresses  produces,  in  the  parts  below  them,  is  the  true  cause  of  the 
changes  in  the  latter  when  inflamed.  Thus  may  the  old  theory  of  derivation 
be  satisfactorily  explained. 

"This  effect  of  cold  applications  may  be  called  into  action  in  some  local 
inflammations  in  which  the  parts  appear  cyanotic  and  it  is  important  to  pre- 
vent impending  suppuration.  Here  hot  compresses  or  cataplasms  are  also 
useful  to  arouse  the  surface  circulation;  as  they  cool  off,  they  widen  the 
deeper  vessels  and  thus  re-establish  the  circulation  which  has  become  stag- 
nant. This  being  accomplished,  cold  compresses  may  succeed  the  hot,  in 
order  to  limit  leucocytosis  and,  by  fluxion,  remove  stagnant  corpuscles.  It 
is  evident  that  by  the  exercise  of  sound  judgment,  the  proper  temperature 
of  the  compress  may  be  nicely  adjusted  to  each  case."  5 

It  must  not  be  supposed  that  circulatory  changes  are  the  only  effects  pro- 
duced by  the  treatment  as  outlined  above.  Proper  regulation  of  the  circu- 
lation by  means  of  heat  and  cold  also  stimulates  the  cells  concerned  in  the 
healing  process. 

From  the  above,  we  may  draw  the  following  conclusions,  as  in  general, 
applicable  to  inflammations.  During  the  acute  stage,  the  treatment  should 
be  directed  toward  the  reducing  of  the  congestion,  whether  by  collateral 
hot  alone,  or  by  hot  assisted  by  cold  over  the  part,  or  by  cold  alone.  The 
philosophy  of  the  treatment  is  summed  up  in  the  word  derivation  as  under- 
stood in  its  broadest  and  practical  sense,  i.  e.,  the  reducing  of  congestion. 
In  the  chronic  stage,  all  the  pathologic  indications  are  met  by  the  produc- 
tion of  fluxion.  The  accompanying  outline  will  serve  to  make  clear  these 
principles: — 

5     Baruch— Principles  and  Practice  of  Hydrotherapy,  pp.  154,  155. 


PRINCIPLES  OF  TREATMENT 


133 


Conditions 

1.  Arterial  hyperemia 

2.  Increasing    serous 

exudate 

3.  Overplus  of  leucocytes 

4.  Bright  red  color 

5.  Pain  severe  and  throb- 

bing 


Acute  Stage 

Indications  for 
Treatment 


Treatment  Should 
Produce 


Limit  congestion  Derivation 

Cause  absorption  of  (Reducing  of  congestion) 

exudate 
Energize  leucocytes 

Relieve  pain 


1.  Passive  hyperemia 

2.  Organization  of  exudate 

3.  Dearth  of  leucocytes 

4.  Dark  red,  dusky  or  blu- 

ish color 

5.  Pain  less  severe  and  dull 


Chronic  Stage 

Stimulate  circulation 
Promote  resolution 
Stimulate  leucocytosis 


Fluxion 

(Increasing  rapidity 
of  circulation) 


We  have  already  referred  to  Bier's  hyperemic  treatment  of  inflammation. 
The  form  of  hyperemia  upon  which  Bier  places  the  greatest  emphasis  and 
which  he  lauds  most  highly  is  the  passive  hyperemia  produced  by  lightly  con- 
stricting bands,  suction  cups,  etc.  These  partially  obstruct  the  return  flow 
of  venous  blood,  so  producing  a  stasis  in  the  part.  The  writer  can  see  no 
rational  basis  for  this  procedure;  in  fact,  to  us,  it  appears  decidedly  irrational 
and  to  in  no  way  meet  the  needs  of  a  chronic  inflammation.  In  this  condi- 
tion, there  is  already  an  extreme  venous  stasis.  To  still  further  slow  the 
blood  current,  certainly  does  not  tend  toward  a  normal  condition.  6  The 
leucocytes  are  neither  renewed,  increased  or  energized.  The  blood,  already 
overcharged  with  acid  products,  is  in  no  way  restored  to  its  normal  degree 
of  alkalinity.  On  the  contrary,  the  production  of  active  hyperemia  meets 
all  these  needs  as  pointed  out  above. 

Meyer  recognizes  only  three  methods  of  producing  hyperemia;  viz.,  by 
elastic  bandages,  cupping  glasses  and  hot  air.  "  Of  these  only  the  hot  air 
produces  an  active  hyperemia  and  while  it  is  exceedingly  useful  in  many  cases, 
it  does  not  produce  the  most  ideal  vascular  condition  for  the  relief  of  chronic 
inflammations  for  the  reasons  already  pointed  out. 

While  the  ice  bag  over  an  inflamed  part,  accompanied  by  collateral  heat 
for  derivative  purposes,  effectually  relieves  the  pain  of  an  inflammatory  pro- 
cess in  soft  tissue,  it  will  not  relieve  the  pain  of  a  bony  inflammation.  To 
decrease  the  congestion  and  relieve  the  pain  of  an  osteomyelitis  or  mastoidi- 
tis  most  effectually,  the  ice  bag  must  be  placed  over  the  trunk  of  the  large 

6  There  is  only  one  organ  in  which  a  passive  congestion,  i.  e,  the  retarding  of  the  blood  current 
can  possibly  result  in  an  "arterial"  hyperemia.      This  organ  is  the  lungs.      In  the  nature  of  the 
case  any  retarding  of  the  outflow  of  blood  from  the  lungs  only  results  in  increasing  the  amount 
of  their  oxygenated  blood.     This  fact  probably  accounts  for  the  relative  inf requency  of  pulmon- 
ary tuberculosis  accompanying  valvular  heart  disease. 

7  Meyer  and  Schmieden — Bier's  Hyperemic  Treatment,  1909,  p.  23. 


m         INFLAMMATION  AND  ANTIPHLOGISTIC  EFFECTS 

artery  supplying  the  inflamed  part  and  not  over  the  part  itself,  while  heat  is 
applied  directly  to  the  inflamed  part.  Ice  applied  over  an  inflammation  con- 
fined in  bony  walls  usually  increases  the  pain,  while  hot  decreases  it. 
Neither  will  the  ice  bag  or  cold  compress  relieve  the  pain  of  an  abscess  even 
in  soft  tissue  or  to  only  a  slight  degree,  lasting  only  while  the  treatment 
continues.  This  very  fact  is  of  diagnostic  importance.  It  is  presumptive 
evidence  that  the  inflammation  has  gone  on  to  suppuration  and  must  be 
opened.  It  should  then  be  treated  by  hot  applications  to  hasten  the  process 
and  localize  the  abscess  preparatory  to  drainage. 


CHAPTER    XIX 

THE  TREATMENT  OF  INFLAMMATIONS 

Inflammations  of  the  Eye 

Iritis,  Keratitis,  Conjunctivitis,  Dachryocystitis,  Ophthalmia,  Tracoma 

Because  of  the  situation,  it  is  necessary  to  use  more  cold  than  hot  in  treat- 
ing these  inflammations,  since  long  hot  applications  to  the  head  produce 
cerebral  congestion.  The  cold  application  may  be  made  by  means  of  four 
to  six  thicknesses  of  gauze  wrung  out  of  ice  water  or  kept  on  a  block  of 
ice,  and  this  applied  almost  continuously,  being  renewed  as  frequently  as 
warmed.  It  may  be  necessary  to  use  a  hot  gauze  compress  occasionally, 
often  enough  to  renew  the  reactive  ability  and  make  the  cold  comfortable 
and  acceptable  to  the  patient.  Short  fomentations  may  be  used  over  the 
side  of  the  face  to  secure  derivation  or,  with  a  small  piece  of  ice  wrapped  in 
gauze  applied  over  the  eye  itself,  a  larger  fomentation  may  be  applied  so  as  to 
cover  the  eye,  forehead  and  cheek.  In  all  cases,  the  hot  applications 
should  be  of  short  duration.  After  the  acuteness  of  the  inflammation  sub- 
sides, small  gauze  fomentations  may  be  used  alternately  with  the  cold  com- 
press, the  hot  being  used  for  a  shorter  time  than  the  cold.  It  is  usually  nec- 
essary to  renew  compresses  about  every  two  minutes.  The  results  are 
apparent  in  the  relief  of  the  congestion,  inflammation  and  pain.  In  ecchymoses 
about  the  eye  the  revulsive  compress  should  be  used. 

In  the  inflammations  mentioned  above,  the  appropriate  antiseptic  treat- 
ment, the  use  of  silver  salts,  etc.,  should  be  followed  just  as  carefully  as 
otherwise  and  in  iritis,  dilatation  of  the  pupil  should  be  secured  by  means 
of  atropin. 

Glaucoma,  Toxic  Amblyopia 

Localized  disturbances  in  the  eye  dependent  upon  systemic  diseases  may 
be  greatly  benefited  by  hydrotherapeutic  treatment.  In  glaucoma  the 
following  treatment  gives  relief  by  reducing  the  vascular  tension.  For  a 
period  of  about  thirty  minutes  give  a  hot  foot  bath  or  hot  leg  bath  together 
with  ice  bags  over  the  carotids  or  apply  the  ice  cravat.  Conclude  the  treat- 
ment by  a  vigorous  cold  mitten  friction  to  the  legs  or  the  alternate  hot 
and  cold  percussion  douche  to  the  feet,  keeping  the  ice  over  the  carotids 
until  its  completion.  During  the  period  of  highest  tension  full  hot  baths 
and  other  heavy  sweating  treatments  must  be  discarded. 

In  toxic  amblyopias,  such  as  tobacco  blindness  and  similar  affections, 
sweating  treatments  combined  with  tonic  measures  are  indispensable.  The 
bowels  should  be  kept  open  by  enemata,  abdominal  massage  and  a  laxative 
diet,  especially  by  the  use  of  fruit.  An  occasional  saline  cathartic  may  be 
necessary. 


136  THE  TREATMENT  OF  INFLAMMATIONS 

Erysipelas 

During  the  first  few  hours,  the  ice  bag  should  be  used  continuously  over 
the  topical  application.  The  ice  bag  is  used  throughout  this  disease  more 
than  in  other  inflammations,  since  new  parts  are  progressively  involved  and 
the  advancing  border  is  therefore  in  the  acute  stage.  An  occasional  fomen- 
tation may  be  necessary  to  renew  the  reactive  capacity  of  the  tissues.  In 
the  case  of  meningeal  involvement,  or  deep  inflammation,  strong  derivative 
means  should  be  used,  as  a  hip  and  leg  pack,  with  the  ice  cap  over  the 
affected  part.  The  latter  should  be  continued  with  but  little  interruption. 
Hot  applications  to  the  head  only  tend  to  increase  the  deep  congestion.  In 
the  case  of  erysipelas  migrans,  very  hot  fomentations,  or  alternately  extreme 
hot  and  cold,  give  the  best  results.  These  should  not  be  used  on  the  head 
or  face,  or  about  the  neck.  The  migratory  form  usually  affects  the  skin  of 
the  trunk  or  limbs. 


Otitis  Media — Acute  Suppurative 

These  cases  rarely  present  themselves  early  enough  to  abort  the  formation 
of  pus  unless  they  come  on  the  first  indication  of  the  closure  of  the  Eustach- 
ian  tube.  The  pain  of  catarrhal  otitis  and  aural  neuralgias  is  best  relieved 
by  fomentations.  After  hot  treatment,  the  patient  should  be  unsually  care- 
ful, since  he  is  rendered  more  susceptible  to  colds.  If  it  seems  probable 
that  rupture  of  the  drum  may  be  prevented,  or  while  waiting  todoparacen- 
tesis  tympani,  the  following  treatment  may  be  used:  Direct  the  patient  to 
take  a  hot  foot  bath,  or  better,  a  leg  bath,  with  fomentation  over  the  ear 
and  side  of  face,  cold  compresses  being  used  to  the  neck  and  opposite  side 
of  the  head.  In  adults,  the  ice  cravat,  or  ice  bag  to  the  carotid  of  the  same 
side  may  be  used.  This  derivation  will  reduce  the  congestion  and  partially, 
or  entirely,  relieve  the  pain.  It  may  also  lessen  the  liability  to  rupture  of 
the  drum. 

Otherwise,  the  condition  should  be  treated  according  to  plans  outlined  in 
any  standard  text  on  diseases  of  the  ear.  The  use  of  hot  air  deserves  men- 
tion as  a  most  efficient  means  in  both  acute  and  chronic  suppurative  otitis 
media. 

Acute  Mastoiditis 

Those  cases  which  tend  toward  recovery,  that  is,  where  the  inflammation 
does  not  go  beyond  turgescence  and  congestion  of  the  lining  membrane  of 
the  mastoid  cells,  may  be  aided  to  an  uneventful  recovery  by  the  use  of 
fomentations  to  the  mastoid,  dry  heat,  and  derivation.  In  infants  and 
younger  children,  the  Leiter  coil  with  ice  water,  may  be  used  over  the 
mastoid.  At  this  age  mastoid  periostitis  is  very  common,  which  condition  is 
always  benefited  by  the  cold  coil.  In  older  children  and  adults,  we  have  not 
been  able  to  use  cold  over  the  mastoid  because  of  the  pain  occasioned  by  it. 

In  many  cases  the  pain  may  be  relieved  by  strong  derivative  means,  as  a 
very  hot  leg  bath  and  fomentations  to  the  mastoid,  with  the  ice  cravat  or 
an  ice  bag  to  the  carotid  of  the  same  side.  This  should  be  continued  from 


ACUTE  TONSILLITIS  137 

20  or  30  minutes  to  an  hour  and  finished  with  a  vigorous  cold  mitten  friction 
to  the  limbs  and  trunk.  We  have  found  this  plan  very  successful  in  obviat- 
ing the  necessity  for  large  doses  of  hypnotic  drugs  in  those  cases  which 
refuse  operation,  or  while  preparations  are  being  made  for  surgical  inter- 
ference. 

Alveolar  Abscess 

This  condition  should  be  treated  on  precisely  the  same  principles  as  mas- 
toiditis,  always  bearing  in  mind  that  the  cure  lies  in  securing  drainage  as 
promptly  as  possible. 

Simple  Pharyngitis 

The  soreness  of  the  throat  is  most  effectually  relieved  by  large  hot  fomen- 
tations to  the  throat,  coming  well  up  under  the  jaw  and  back  to  the  ears. 
If  there  is  much  fever,  a  mild  sweating  treatment  will  be  beneficial  at  the 
beginning.  This  may  be  accomplished  by  a  hot  foot  bath  with  the  fomenta- 
tions to  the  throat,  or  an  electric  light  bath.  The  treatment  should  be  con- 
cluded with  a  cold  mitten  friction,  and  a  heating  compress  applied  to  the 
throat  to  be  left  over  night.  The  next  day,  use  the  hot  foot  bath  and  revul- 
sive compress  to  the  throat.  Each  hot  treatment  should  be  concluded  with 
some  tonic  measure,  such  as  the  cold  mitten  friction,  cold  towel  rub,  gradu- 
ated or  hot  and  cold  spray.  It  may  be  necessary  to  repeat  the  hot  foot  bath 
and  revulsive  compress  two  or  three  times  a  day,  always  leaving  the  heat- 
ing compress  in  place  between  treatments  and  over  night.  The  inhalation 
of  steam  and  gargling  of  hot  water  will  aid  in  relieving  the  pain.  The  ordin- 
ary antiseptic  throat  gargles  in  hot  water  should  also  be  used. 

Acute  Tonsillitis 

The  temperature  is  usually  very  high,  but  of  a  transient  type.  It  is 
unnecessary  to  employ  antipyretic  measures.  In  fact,  general  applications 
of  cold  are  quite  likely  to  produce  chilling.  At  the  beginning  of  treatment, 
the  patient  should  be  given  some  sweating  measure,  such  as  a  hot  leg  pack, 
full  blanket  pack,  or  hot  leg  bath  with  fomentations  to  the  throat  and  ice 
compress  or  ice  cap  to  the  top  and  sides  of  the  head.  Because  of  the  rapid 
pulse  and  extreme  prostration,  an  ice  bag  should  be  applied  to  the  heart. 
The  patient  may  be  taken  out  with  a  cold  mitten  friction,  or,  if  able  to  stand, 
a  graduated  shower.  A  well  covered  heating  compress  should  be  applied  to 
the  neck.  After  the  initial  treatment,  fomentations  or  the  revulsive  com- 
press should  be  applied  to  the  neck  at  frequent  intervals,  always  following 
them  by  the  heating  compress.  Throughout  the  disease,  very  vigorous 
tonic  treatment  may  be  employed.  The  cold  mitten  friction,  or  cold  towel 
rub,  wet  sheet  pack,  etc.,  have  been  found  useful  in  maintaining  the 
vitality  of  the  patient. 

In  case  of  quinsy,  the  paratonsillar  abscess  should  be  lanced  at  the  proper 
time.  Previous  to  this,  fomentations  frequently  repeated  will  aid  in  hasten- 
ing suppuration,  localizing  the  abscess  and  making  more  apparent  the  point- 
ing. 


138  THE  TREATMENT  OF  INFLAMMATIONS 

Boils  and  Carbuncles 

In  the  beginning,  while  the  boil  is  only  a  pimple,  it  may  be  aborted  by  the 
prolonged  use  of  ice  over  it,  with  a  fomentation  covering  it  and  a  larger 
area,  applied  at  the  same  time.  The  use  of  extreme  hot  and  cold  applica- 
tions, alternately  applied  (fluxion),  is  also  an  advantage.  When  it  is  no 
longer  possible  to  stop  the  progress  of  the  boil,  fomentations,  poultices, 
heating  compresses,  etc.,  may  be  used  to  relieve  the  pain  and  hasten  the 
localization  of  the  pus.  It  should  then  be  lanced.  The  absorption  of  the 
indurated  residue  about  the  boil  may  be  hastened  by  hot  and  cold  applications, 
such  as  fomentations  and  ice  or  the  alternate  hot  and  cold  pour.  Pressure 
about  the  boil,  or  friction  to  the  skin  should  be  avoided,  as  these  measures 
tend  to  spreading  of  the  bacteria  and  the  infection  of  other  areas. 

Acute  Blood  Poisoning 

Septiceniia  of  Hand,  Foot,  etc.  These  infections  are  usually  occasioned  by 
scratches,  cuts,  bruises,  tharns,  etc.  While  the  initial  lesion  may  seem  to 
be  trivial,  serious  results  follow  very  quickly.  For  this  reason,  blood  pois- 
oning should  be  treated  most  vigorously.  The  object  to  be  accomplished  is 
the  increasing  of  phagocytosis  and  so  increasing  the  circulation  as  to  rapidly 
renew  the  blood  flowing  through  the  infected  part,  When  first  seen  by  the 
physician,  the  inflammation  has  usually  gone  beyond  the  primary  stage.  In 
the  case  of  the  hand,  the  part  is  very  much  swollen,  blue  and  edematous. 
Extension  of  the  infection  is  indicated  by  red  lines  (lymphangitis)  extend- 
ing upward,  and  by  swelling  and  tenderness  of  the  regional  lymphatics. 
When  this  occurs,  most  prompt  and  vigorous  measures  are  neccessary.  The 
following  treatment,  if  applied  reasonably  early,  has,  in  the  writer's  exper- 
ience, never  failed  of  success: — 

Provide  two  pails  or  receptacles  sufficiently  large  to  immerse  the  infected 
part.  One  of  these  should  be  filled  with  the  hottest  water  that  can  be  borne, 
more  being  added  from  time  to  time  to  the  limit  of  toleration.  The  other 
pail  should  be  filled  with  ice  water,  containing  pieces  of  ice.  The  patient  is 
instracted  to  immerse  the  part  in  the  hot  water  for  2  minutes,  then  in  the 
cold  for  15  to  30  seconds,  after  which,  it  is  returned  to  the  hot  water  again 
for  1-J  or  2  minutes,  then  re-immersed  in  the  cold  for  15  to  30  seconds.  These 
changes  are  kept  up  for  at  least  half  an  hour  and  repeated  from  two  to  four 
or  five  times  a  day,  according  to  the  seriousness  of  the  infection.  If  thought 
best,  disinfectants  may  be  added  to  both  the  hot  and  cold  water.  We  have 
used  crystals  of  potassium  permanganate  in  one  and  oxalic  acid  crystals  in 
the  other. 

It  may  be  necessary  to  lance  the  part  if  there  are  signs  of  suppuration. 
This  should  be  done  anyway  if  the  infection  has  stood  some  time  without 
treatment,  or  if  extreme  swelling  and  edema  exist.  In  the  latter  case, 
multiple  openings  may  be  necessary.  Massage  should  be  avoided  altogether, 
as  it  spreads  the  bacteria  along  the  lymph  channels. 

Cases  treated  as  outlined  above  require  only  a  few  days  for  a  complete 
cure,  while  cases  treated  by  poulticing,  antiseptics,  incisions,  without  hydro- 
therapy,  usually  run  a  course  of  from  a  week  to  a  month,  or  even  longer. 


PNEUMONIA  139 

Some  cases  of  gangrene  are  successfully  treated  by  this  method.  The 
appearance  of  the  line  of  demarkation  may  be  hastened  by  the  use  of  alter- 
nate hot  and  cold  applications. 

Chronic  cases  of  osteomyelitis,  with  much  riddling  of  the  bone  and  soft 
parts,  with  sinuses,  sequestrum  formation,  etc.,  are  successfully  treated 
along  the  same  lines.  The  use  of  von  Mosetig's  bone-wax  followed  by  the 
alternate  hot  and  cold  pour,  applied  daily,  gives  good  results. 

Poison  Ivy  and  Oak 

These  inflammations  require  some  active  antiseptic  treatment.  In  the 
earlier  stages,  continuous  cold  compresses,  or  the  ice  bag  may  be  used  with 
benefit.  Later  on,  vigorous  hot  and  cold  compresses,  pours  or  sprays  give 
the  best  results.  This  latter  means  has  proven  of  inestimable  value  in  long- 
standing, refractory  cases. 

Pneumonia 

Pneumonia  is  an  acute,  self-limited  infectious  disease  characterized 
by  a  general  toxemia  and,  pathologically,  by  a  definite  series  of  changes  in 
the  lungs.  The  first  stage  is  that  of  intense  pulmonary  congestion.  In  the 
second  stage,  there  is  exudation  into  the  alveoli,  so  that  the  affected  lobe 
becomes  consolidated,  the  condition  being  known  as  red  hepatization.  The 
third  stage — gray  hepatization — is  marked  by  the  changes  accompaning  reso- 
lution. The  clinical  feature  of  the  crisis  marks  the  transition  from  the 
second  to  the  third  stage  and  the  beginning  of  resolution.  Clinically,  the 
following  symptoms  are  prominent:  pain  in  the  chest,  dyspnoaa,  with  rapid 
respiration,  more  or  less  cyanosis,  and  cough  accompanied  by  the  expec- 
toration of  "prune-juice"  or  "rusty"  sputum.  Pneumonia  runs  a  short 
course  and,  if  the  resistance  of  the  patient  is  sufficient,  antitoxines  are  pro- 
duced quite  rapidly,  so  that  the  progress  of  the  infection  Is  arrested.  It 
should  be  recognized  that  pneumonia  is  a  general  infection,  much  like  typhoid, 
and  therefore  demands  systemic  treatment. 

The  greatest  danger  in  pneumonia  arises  from  two  causes  principally, — 
(1)  deficient  aeration  of  the  blood  and  (2)  failure  of  the  circulation.  The 
air  hunger  is  manifest  by  the  rapid  respiration,  dyspnoea  and  cyanosis.  In 
all  febrile  conditions  there  is,  on  the  part  of  the  tissues,  a  lessened  capacity 
for  the  absorption  of  oxygen.  In  pneumonia,  beside  this,  the  lung  area 
for  gaseous  interchange  is  very  much  limited  because  of  the  consolidation. 
The  stasis  of  the  blood  in  the  lungs  tends  to  increase  the  difficulty.  The 
right  heart  is  particularly  embarrassed  because  of  the  lung  consolidation 
and  the  pulmonary  stasis.  It  has  difficulty  in  forcing  a  sufficient  amount  of 
blood  through  the  lungs  to  provide  the  tissues  with  the  proper  amount  of 
oxygen.  There  is  increased  pressure  in  the  right  ventricle,  as  evidenced  by 
the  accentuated  second  pulmonic  sound.  The  absence  of  this  sign  is  one  of 
the  evidences  of  failure  of  the  right  heart  and  dilatation  of  the  right  ven- 
tricle. 

In  those  cases  due  to  alcohol,  the  blood  vessels  are  in  a  state  of  passive 
dilatation  from  paresis  of  the  vasomotors.  Both  the  capillary  vessels  of 


140  THE  TREATMENT  OF  INFLAMMATIONS 

the  lungs  and  those  of  the  general  periphery  are  in  this  condition.  It  is  be- 
cause of  this  pare  tic  condition  of  the  vessels  and  the  failure  of  the  narcot- 
ized cutaneous  nerves  to  appreciate  the  danger  from  cold  that  retrostasis  is 
so  likely  to  occur.  Pneumonia  is  especially  fatal  in  alcoholics.  There  should 
be  a  high  leucocytosis.  The  absence  of  this  is  one  of  the  unfavorable  signs. 
From  the  foregoing,  we  may  select  four  indications  of  prime  importance 
in  the  treatment  of  pneumonia.  1.  Increase  the  aeration  of  the  blood. 
2.  Sustain  the  heart  and  circulation.  3.  Increase  leucocytosis  and  pha- 
gocytosis in  order  to  combat  the  infection.  4.  Decrease  toxemia. 

Treatment 

Pneumonia  as  such  does  not  exist  until  the  stage  of  exudation  and  consoli- 
dation. The  pulmonary  congestion,  however  intense,  does  not  constitute 
pneumonia,  although  if  pneumococci  are  present,  it  is  quite  likely  to  end  in 
consolidation.  It  is  impossible  to  abort  pneumonia  after  the  exudation  has 
occurred,  although  it  is  possible,  by  strong  derivative  means,  to  reduce  even  a 
very  intense  pulmonary  congestion.  The  presence  of  numerous  crepitant 
rales  is  not,  in  itself,  evidence  of  consolidation.  The  rales,  together  with 
rapid  respiration,  pain  and  fever,  may  be  present  in  the  stage  of  congestion 
before  exudation  has  occurred.  If  treatment  can  be  begun  very  early,  even 
though  there  is  no  positive  assurance  that  the  condition  is  not  more  than  a 
congestion,  it  is  best  to  employ  some  derivative,  or  sweating  treatment  in 
order  to  reduce  as  much  as  possible  the  pulmonary  congestion.  The  collat- 
eral heat  may  be  either  a  very  hot  leg  bath,  a  hot  hip  and  leg  pack,  or  full 
blanket  pack.  The  latter  will  be  best  if  the  patient  is  very  chilly.  These 
measures  should  be  re-enforced  by  the  drinking  of  some  hot  liquid  to  pro- 
duce perspiration  and  thus  aid  in  reducing  the  internal  congestion.  In  apply- 
ing the  cold  to  the  chest,  it  must  be  born  in  mind  that  the  lobes  affected  are 
usually  the  lower  lobes  and  therefore  present  the  greater  surface  at  the  sides 
and  back  of  the  chest.  Over  this  area  may  be  used  a  very  large  ice  cap  or 
ice  pack.  This  Should  not  be  placed  until  the  patient  is  well  warmed,  since 
otherwise  it  may  produce  chilliness.  The  collateral  heat  and  local  cold 
should  be  continued  until  effectual  derivation  is  secured.  If  this  requires 
a  very  long  time,  the  pack  must  be  re-enforced  by  hot  water  bottles,  bricks, 
etc.,  and  the  cold  over  the  affected  lobe  replaced  for  a  short  time  by  a  very 
hot  fomentation  to  renew  the  nerve  sensibility  and  promote  the  vigor  of  the 
reflex  effect  from  the  cold.  It  is  well  to  use  the  ice  bag  over  the  heart  if  the 
pulse  is  very  rapid.  Treatment  may  be  concluded  with  a  cold  mitten  fric- 
tion. A  very  short  fomentation  may  be  applied  to  the  chest,  followed  by  a 
heating  compress  or  a  moist  chest  pack  which  should  be  left  in  place  until 
the  next  treatment. 

The  supplying  of  plenty  of  fresh  cold  air  is  of  prime  importance.  It  has 
been  stated  that,  during  the  late  war,  cases  of  pneumonia  treated  in  tents 
in  the  most  rigorous  weather  did  far  better  than  those  treated  in  hospital 
buildings.  The  open  air  treatment  as  carried  out  in  some  hospitals  has  greatly 
reduced  the  mortality.  The  laity  fear  the  effects  of  cold  air  in  this  disease, 
believing  that  the  patient  is  likely  to  take  cold  and  so  the  pneumonia  be 
made  woi'se.  Persons  with  fever  are  not  likely  to  suffer  from  an  "overdose" 
of  cold  air.  For  the  reason  stated  above,  it  is  very  necessary  that  the  lungs 


PNEUMONIA  Ul 

be  supplied  with  the  greatest  possible  amount  of  pure  fresh  air.  Neither 
should  the  air  be  warmed.  The  depth  of  respiration  is  stimulated  by  the 
cold.  All  the  cold  treatments  given  in  the  hydriatic  management  of  pneu- 
monia increase  the  depth  of  respiration  and  so  enable  the  body  to  make  use 
of  the  oxygen  supplied  by  the  fresh  air.  This  is  true  of  the  cold  compress, 
the  heating  compress,  the  ice  pack  and  cold  rubs  and  frictions.  If  it  is  not 
possible,  because  of  the  season,  to  obtain  very  cold  air,  much  might  be 
saved  in  the  mortality  by  providing  means  of  refrigerating  the  air  supplied 
to  the  patient.  The  air  may  be  supplied  through  a  hood  fitted  into  the  open- 
ing made  by  raising  the  lower  sash  of  any  ordinary  window.  The  other  end 
of  the  hood  should  fit  down  over  the  head  of  the  patient  and  can  be  tucked 
in  about  the  pillow,  coming  no  lower  than  just  under  the  chin.  This  may 
be  arranged  with  glass  windows  so  as  to  obviate  the  necessity  of  removing 
the  hood  for  observation  of  the  patient,  etc.  Those  who  have  lived  in  the 
Arctic  regions,  Labrador  and  other  very  cold  climates,  tell  us  that  pneumonia 
and  tuberculosis  are  rare  diseases  there  and  in  some  places  almost  unknown. 

Relative  to  the  beneficial  effects  of  fresh  air  in  febrile  diseases,  the  fol- 
lowing is  related  of  Dr.  Alonzo  Clarke:— 

"It  is  interesting  to  read  how  he  managed  typus  fever  in  Bellevue  Hospi- 
tal. There  were  250  cases  constantly  under  his  care,  and  as  many  more 
under  the  care  of  his  colleagues.  The  mortality  was  great.  Precautions 
against  the  draughts  of  air,  for  fear  of  pneumonia,  were  carefully  adopted. 
Dr.  Clarke,  not  having  this  dread,  ordered  that  there  should  be  the  freest 
ventilation,  with  scrupulous  cleanliness.  Although  it  was  winter,  the  win- 
dows were  removed,  stoves  were  placed  before  the  open  spaces  to  raise  the 
temperature  of  the  incoming  air,  clothing  was  increased,  stimulants  were 
given  in  moderate  quantities,  and  other  medicine  mostly  dispensed  with.  Of 
the  250  cases  not  a  death  occurred  in  the  period  of  a  fortnight.  In  two 
weeks  they  were  convalescent.  In  other  wards  of  the  hospital  where  the 
management  was  unchanged,  the  mortality  was  undiminished. " 

The  sustaining  of  the  heart  and  circulation  is  best  accomplished  by  judi- 
cious hydrotherapy.  Romberg  and  Passler  have  shown  that  the  toxic  albu- 
minoid produced  by  the  pneumococcus  paralyzes  the  vasomotor  center  in  the 
medulla,  and  Passler  regards  this  as  the  most  common  cause  of  death  in 
pneumonia  as  far  as  the  circulation  is  concerned.  Vasomotor  tonics  are  as 
essential  in  pneumonia  as  in  other  febrile  diseases  and  the  effect  of  hydro- 
therapy  as  a  vasomotor  stimulant  is  its  most  important  asset  in  this  disease. 
Hand  in  hand  with  this  effect  goes  stimulation  of  respiration  and  of  the  heart 
itself.  The  cold  compress  to  the  chest  is  applicable  in  all  cases.  An  ordi- 
nary linen  towel  or  hand  towel  may  be  used  for  this  purpose,  two  or  three 
thicknesses  of  cloth  usually  being  sufficient.  It  should  be  wrung  from  ice 
water  and  applied  to  the  front  and  sides  of  the  chest  and  covered  with  a 
flannel  cloth.  If  desired  to  greatly  stimulate  respiration  and  the  heart 
action,  it  should  be  frequently  renewed.  In  ordinary  cases,  it  may  be  left 
on  fifteen,  twenty  or  thirty  minutes  at  a  time.  While  the  patient  is  sleep- 
ing or  when  it  is  desired  to  give  rest,  the  compress  should  be  left  on  an 
hour  or  two.  It  then  becomes  a  heating  compress. 

The  square  or  roller   chest   pack  is  an  excellent   means  of  applying  the 


142  THE  TREATMENT  OF  INFLAMMATIONS 

principles  of  the  heating  compress.  It  has  the  advantage  of  the  heating 
compress  in  that  a  greater  area  is  treated  and  undue  circulation  of  the  air 
about  the  wet  cloth  more  perfectly  prevented.  It  should  be  left  in  place 
two  or  three  hours,  or  may  be  put  on  and  left  over  night,  unless  necessary 
to  give  other  treatments. 

In  case  of  strong,  vigorous  men,  it  is  possible  to  use  with  benefit  the  ice 
pack  to  the  chest.  The  ice  may  be  supplied  by  means  of  several  ice  bags 
adjusted  to  cover  the  skin  surface  over  the  affected  lobe,  or  it  may  be  made  by 
placing  cracked  ice  in  a  Turkish  towel  and  covering  the  whole  with  oiled  silk 
or  gossamer  cloth  so  as  to  prevent  wetting  the  clothing  and  bedding.  These 
packs  may  be  left  in  place  almost  continuously,  applying  every  thirty  min- 
utes or  every  hour  one  or  two  short  fomentations;  and  every  three  or  four 
hours,  replacing  the  pack  by  the  heating  compress,  allowing  the  latter  to 
remain  thirty  minutes  or  an  hour.  The  ice  pack  should  not  be  used  where 
the  patient  is  inclined  to  be  chilly,  or  with  thin  patients  and  those  of  low 
vitality.  Whenever  it  is  used,  the  limbs  should  be  kept  warm  by  the  use 
of  hot  water  bottles.  It  is  well  also  to  give  a  hot  foot  bath  or  leg  pack  at 
intervals  of  five  or  six  hours. 

The  cold  mitten  friction  and  the  cold  towel  rub  are  invaluable  in  aiding 
the  circulation  and  sustaining  the  heart.  It  may  be  necessary  where  there 
is  cold  clammy  perspiration,  chilliness  or  cyanosis,  to  precede  the  cold  treat- 
ment by  short  fomentations  applied  to  the  limb  or  part  just  previous  to  the 
cold  mitten  friction.  If  the  heart  is  very  much  embarrassed,  it  may  be 
greatly  relieved  and  the  patient  tided  over  a  crisis  by  the  use  of  short  hot 
applications  as  just  mentioned,  and  immediately  succeeded  by  the  cold  mitten 
friction  given  until  the  skin  is  red  and  reaction  complete.  The  part  should 
then  be  very  rapidily  dried  with  a  rough  towel.  Dry  friction  and  percussion 
should  follow  in  order  to  secure  thorough  reaction.  There  are  two  princi- 
ples involved  in  this  method, — first,  the  stimulation  of  the  peripheral  circula- 
tion so  as  to  relieve  the  heart  of  its  added  burden;  and  second,  because  of 
the  tonic  dilatation  of  the  surface  vessels,  there  is  produced  a  very  decided 
and  lasting  derivation,  so  that  the  extreme  engorgement  of  the  heart  and 
lungs  is  relieved. 

A  warm  bath  at  98°  or  100°  gradually  cooled  to  90°  is  highly  recommended 
by  some.  The  effect  of  this  treatment  may  be  very  much  increased  by  allow- 
ing the  patient  to  remain  just  long  enough  to  secure  a  thorough  warming, 
cold  applications  to  the  head  and  heart  being  kept  in  place  during  this  time. 
The  patient  then  sits  up  while  he  receives  to  the  chest,  shoulders  and  back 
two  to  four  affusions  of  water  at  90°.  This  stimulates  respiration  and 
increases  the  efficiency  of  expectoration. 

Some  have  very  highly  recommended  the  Brand  bath  in  lobar  pneumonia. 
We  can  see  no  advantage  in  this  measure  over  the  others  mentioned  and  can 
readily  understand  that  in  many  cases  it  might  prove  dangerous,  as  the 
heart  and  lungs  are  unable  to  withstand  the  retrostasis  occasioned  by  the 
initial  anemia  of  the  skin,  which  follows  contact  with  the  cold  water.  In 
general,  it  may  be  said  that  full  tub  baths  are  not  applicable  in  pneumonia. 

Pain.  The  pain  in  pneumonia  is  due  chiefly  to  the  accompanying  pleurisy. 
The  inflammation  is  largely  on  the  side  of  the  visceral  layer  and  so  does  not 


PNEUMONIA  143 

counterindicate  the  use  of  cold  applications.  Pain  is  perhaps  best  relieved 
by  the  use  of  hot  fomentations.  These  should  be  large  enough  to  cover  an 
entire  side  of  the  chest  and  are  more  efficient  when  applied  from  spine  to 
sternum  with  the  patient  lying  on  the  opposite  side.  The  chest  pack  or 
heating  compress  should  follow  the  hot  treatment. 

Cough  and  Expectoration.  All  of  the  treatments  recommended  above  are 
beneficial  in  aiding  the  expulsion  of  mucus.  A  severe  cough  may  be  relieved 
by  the  use  of  fomentations  and  the  heating  compress.  Inhalations  of  steam 
are  also  beneficial.  The  revulsive  compress  is  perhaps  the  most  efficient 
means  in  stimulating  expectoration.  A  large  fomentation  is  first  applied; 
as  soon  as  the  heat  begins  to  subside,  it  should  be  replaced  by  a  towel  wrung 
from  ice  water.  This  should  be  left  on  until  it  has  become  slightly  heated, 
perhaps  1  to  3  minutes.  The  part  should  be  dried  and  the  second  fomenta- 
tion applied.  Three  or  four  changes  are  usually  sufficient  to  accomplish  the 
desired  result.  A  revulsive  compress  also  stimulates  the  heart  and  increases 
the  depth  of  respiration  and  the  consequent  aeration  of  the  blood. 

The  patient  should  drink  large  quantities  of  water  by  taking  it  frequently 
in  small  amounts.  This  increases  diuresis  and  the  elimination  of  toxines. 
Either  hot  or  cold  water  may  be  used  according  to  indications.  The  bowels 
should  be  kept  open  by  salines  and  enemata  as  needed.  A  very  light  diet 
low  in  proteid  also  aids  in  limiting  the  toxemia. 

Medicinal   Treatment 

Quinin.  So  much  has  recently  been  written  concerning  the  use  of  large 
doses  of  quinin  in  the  treatment  of  pneumonia  that  no  discussion  of  this  dis- 
ease would  be  complete  without  reference  to  its  effects. 

"It  has  been  suggested  that  its  efficiency  in  fever  is  due  to  an  antiseptic 
action  on  the  blood.  This  is  not  the  case,  since  bacteria  are  very  resistant 
to  it  and  would  not  be  affected  by  it  in  the  concentration  in  which  it  could 
exist  in  the  blood."  l  It  does  certainly  reduce  the  temperature  as  we  have 
previously  noted,  but  this  is  not  of  prime  importance  in  pneumonia.  Anti- 
pyresis  is  of  secondary  importance,  nor  do  patients  bear  great  abstraction 
of  heat,  as  is  the  case  in  typhoid  fever.  The  temperature  is  lowered  at  the 
expense  of  the  heart's  action  and  oxygen-carrying  capacity  of  the  red  blood 
cells.  Both  of  these,  it  is  necessary  to  sustain  and  enhance  in  pneumonia. 
Quinin  limits  leucocytosis  and  checks  phagocytosis.  If  20  to  30  grains  are 
given  daily,  the  disease  is  likely  to  run  an  atypical  course,  there  being  no 
frank  crisis,  which  is  replaced  by  very  much  delayed  resolution,  the  fever 
declining  by  lysis. 

Moist  rales  may  be  heard  in  the  chest  long  after  resolution  should  be  com- 
plete. One  area  will  hardly  more  than  clear  up  before  another  area  is  in- 
volved, so  that  by  delayed  resolution  and  re-involvement  of  another  area,  the 
pathology  assumes  a  sort  of  migratory  type.  Probably  the  reason  for  the 
failure  in  the  appearance  of  the  crisis  is  due  to  the  fact  that  the  sthenic 
condition  has  been  reduced  to  an  asthenia,  the  system  lacking  sufficient  vi- 
tality to  produce  a  normal  crisis.  Anyone  who  will  take  the  trouble  to 
"read  up"  on  the  effects  of  quinin  will  soon  be  convinced  of  its  harjnful- 

1    Sollmann— Text  Book  of  Pharmacology,  p.  350. 


144  THE  TREATMENT  OF  INFLAMMATIONS 

ness  in  pneumonia.  The  caution  sounded  by  Dr.  W.  C.  Alvarez  in  a  recent 
letter  published  in  the  Journal  of  the  American  Medical  Association  is  cer- 
tainly timely. 2  In  a  personal  communication  received  from  Dr.  Alvarez,  he 
states  that  among  the  many  letters  he  received  after  the  publishing  of  this 
communication  to  the  Journal,  one  came  from  a  fellow  practitioner  who 
was  much  in  favor  of  the  quinin  treatment,  but  had  recently  had,  among 
a  small  series,  seven  bad  cases  of  empyema.  On  the  ordinary  expectant 
plan,  it  should  take  200  to  400  cases  of  pneumonia  to  furnish  seven  of  em- 
pyema. The  white  blood  cells  were  paralyzed  by  the  quinin  and  so  easily 
succumbed  to  the  infection.  Too  much  can  not  be  said  condemnatory  of  the 
quinin  treatment  of  pneumonia. 

.  Strychnin.  This  drug  has  been  very  much  vaunted  as  a  specific  in  meet- 
ing cardiac  incompetency  in  pneumonia.  Much  to  the  discredit  of  the  pro- 
fession generally,  a  plan  frequently  followed  is  that  of  giving  1-60  grain  of 
strychnin  every  3  hours,  this  being  kept  up  during  the  greater  part  of  the 
illness.  As  some  one  has  said,  "continual  doping  with  strychnin  to  the  heart 
is  like  kicking  a  dying  horse  when  he  is  down."  As  we  have  already  shown, 
the  results  hoped  from  strychnin  are  best  attained  by  proper  hydriatic  means. 

Frank  Billings3  says,  "Strychnin  and  other  drugs  that  are  commonly  used 
in  failing  left  heart  are  absolutely  valueless  except  to  stimulate  nerve  cen- 
ters: strychnin  will  not  raise  the  blood  pressure  1  mm.  I  have  used  it  over 
and  over  again.  .  .  .  Finally,  the  watchful  and  vigilant  care  of  patients 
afflicted  with  pneumonia  without  the  use  of  drugs  is  the  ideal  treatment." 

Relative  to  the  routine  use  of  digitalis  in  pneumonia  F.  Forchheimer4 
relates  his  experience  following  the  use  of  large  doses  as  advised  by  Petresco 
of  Bucharest.  He  says  the  "mortality  was  greater  than  before.  All  the 
evil  effects  that  can  be  produced  by  digitalis  were  noted,  and  after  three 
days  of  administration  of  the  remedy  such  cumulative  effects  were  pro- 
duced as  I  shall  hope  never  to  see  again." 

Alcotiol.  When  we  stop  to  think  of  it,  it  must  seem  strange  to  any  sane 
man  to  suppose  that  a  drug  which  increases  the  liability  to  pneumonia  and 
greatly  increases  its  mortality  should  ever  be  recommended  as  a  therapeutic 
agent  in  that  disease.  Yet  that  such  has  been  done  is  evidenced  by  the  num- 
erous articles  which,  a  few  years  ago,  appeared  in  many  medical  journals, 
recommending  whiskey  and  brandy  as  a  routine  treatment  of  pneumonia. 
It  is  supposed  that  by  dilating  the  peripheral  vessels,  it  aids  in  decreasing 
the  congestion  of  the  lungs.  This  might  be  the  case,  did  not  alcohol  act  upon 
all  the  small  blood  vessels,  those  of  the  lungs  included.  Neither  is  alcohol 
a  cardiac  stimulant  as  has  more  recently  been  shown  by  numerous  reliable 
experiments.  Experiments  by  Martin  and  Stevens,  conducted  in  the  Biolog- 
ical Laboratory  of  the  John  Hopkins  University,  show  that  blood  containing 
J  of  1  per  cent  of  alcohol  diminished  within  a  single  minute  the  work  done 
by  the  heart  and  that  in  certain  animals  experimented  on,  blood  containing 
|  to  1  per  cent  of  alcohol  so  seriously  affected  its  working  powers  that  it 
was  scarcely  able  to  drive  a  sufficient  amount  of  blood  to  supply  its  own 

2  Journal  of  American  Medical  Association,  June  13,  1908,  p.  1996. 

3  Ibid.,  October  30,  1909,  p.  1453. 

4  Ibid.  p.  1450. 


BRONCHOPNEUMONIA  U5 

nutrient  arteries.  Doctor  Monroe  of  Glasgow  Royal  Infirmary  says,  "It  has 
yet  to  be  proved  that  the  heart  muscle  can  be  stimulated  by  alcohol." 

In  a  paper  by  E.  Lewis  Backman  -before  the  Anti-Alcohol  Congress  at 
Stockholm,  it  was  shown  that  when  a  solution  containing  from  .0025  per  cent 
to  .5  per  cent  were  passed  through  the  vessels  of  the  isolated  heart,  in  the 
case  of  the  rabbit,  that  if  the  amount  were  sufficiently  large  to  produce 
any  noticeable  effect,  there  was  manifest  temporary  irregularity  and  dimi- 
nution of  the  strength  of  the  contraction,  or  a  lasting  arrythmia,  and  a 
considerable  reduction  in  the  volume  and  the  number  of  the  pulsations. 
Alcohol  also  limits  or  annihilates  phagocytic  action. 

John  H.  Musser 5  gives  the  following  summary  concerning  the  treatment 
of  pneumonia:  "In  the  majority  of  the  cases  I  prefer  to  rely  on  fresh 
air,  on  judicious  local  treatment,  on  hydrotherapeutics,  on  regulation 
of  the  proper  amount  of  food  taken,  and  particularly  on  care  that  the 
patient  is  not  overfed.  I  watch  carefully  for  the  phenomena  so  well 
pictured  by  Doctor  Forchheimer,  guarding  against  the  possibility  of  the  vaso- 
motor  syndrome  by  proper  renal  elimination.  Attention  to  proper  elim- 
ination is  of  the  greatest  importance  in  the  management  of  the  cases  of 
pneumonia,  looking  toward  the  prevention  of  cardiac  failure;  in  other  words, 
looking  toward  the  reduction  of  serious  toxic  symptoms  that  arise  and  have 
expression  more  particularly  in  the  phenomena  just  pointed  out.  To  keep 
down  the  amount  of  food  is  of  the  greatest  importance  in  the  management 
of  pneumonia  patients.  Watch  carefully  the  state  of  the  intestinal  tract. 
Tympany  is  a  serious  toxic  symptom  in  pneumonia  and  its  increase  with 
defective  elimination  is  a  point  that  I  depend  on  as  suggestive  of  the  occur- 
rance  of  vasomotor  failure.  This  can  be  prevented  very  largely.  Colitis 
occurs  with  the  pneumococcus  infection,  and  this  colitis  is  undoubtedly  the 
cause  of  the  development  of  tympanites;  the  colitis  plus  the  toxemia  invites 
an  intestinal  paresis.  Hence  to  prevent  this  colitis  which  gives  rise  to  the 
tympany,  it  is  well  to  observe  carefully  the  diet,  regulating  judiciously  the 
amount  and  kind  of  food  taken,  and  washing  out  the  bowels  with  normal 
salt  solution." 

Bronchopneumonia 

Under  two  years  of  age,  lobar  pneumonia  is  seldom  ever  seen.  From 
this  up  to  seven,  either  type  may  be  found.  After  that  age,  lobar  pneumo- 
nia is  the  prevailing  form.  In  many  ways,  the  treatment  of  bronchopneu- 
monia  is  conducted  on  the  same  principles  as  that  for  the  lobar  type.  The 
first  two  indications,  i.  e.,  increase  aeration  of  the  blood  and  sustain  the 
heart  and  circulation,  are  the  most  important.  Bronchopneumonia  is 
nothing  more  nor  less  than  an  extension  downward  of  the  inflammation  of 
a  bronchitis.  It  is  a  capillary  bronchitis  or  lobular  pneumonia.  In  order  to 
accomplish  the  first  result,  the  proper  aeration  of  the  blood,  it  is  very 
necessary  to  increase  the  facility  and  the  amount  of  expectoration,  so  that 
the  lungs  may  be  free  for  proper  respiration.  The  child  may  be  placed  in 
a  bath  at  100°  and,  while  sitting,  receive  to  the  chest  and  shoulders  cold  affus- 
ions at  75°  to  90°,  depending  upon  the  age  and  vitality.  With  infants,  the 
wet  sheet  pack  is  perhaps  the  most  efficient  means.  The  pack  may  be 

5    Ibid.,  p.  1453. 


146  THE  TREATMENT  OF  INFLAMMATIONS 

wrung  from  tepid,  cool  or  cold  water  and  spread  out  on  a  blanket.  The 
child  is  then  placed  on  the  -wet  sheet  which  is  wrapped  snugly  about  the 
body,  the  blanket  being  folded  over.  all.  The  child  should  remain  in  the 
pack  to  the  sweating  stage.  At  first,  there  is  gasping  respiration  and  the 
child  cries.  This  aids  in  the  expulsion  of  mucus.  As  the  pack  heats  up, 
the  respiration  becomes  deeper,  easier  and  the  expectoration  much  less  diffi- 
cult. Fever  may  drop  one  or  two  degrees  and  the  child  pass  into  a  quiet 
sleep.  If  this  occurs,  the  child  should  be  kept  warm,  being  left  in  the  pack 
until  it  awakes.  It  may  then  be  taken  out  with  a  wet  hand  rub,  or  this  may 
be  done  sooner  if  the  child  does  not  sleep.  The  moist  chest  pack  and  heat- 
ing compress  to  the  chest  are  also  efficient  means  of  sustaining  the  heart 
and  increasing  the  depth  of  respiration.  If  there  is  much  cyanosis,  espec- 
ially if  accompanied  by  chilliness,  it  is  best  to  place  the  child  in  a  full  warm 
bath;  or,  if  the  pack  is  used,  it  may  be  wrung  from  warm  water  or  hot 
water.  In  case  of  the  bath,  after  the  skin  has  become  well  warmed,  the 
child  may  receive  an  affusion  to  the  chest  or  to  the  entire  body  just  as  it  is 
taken  from  the  bath.  In  case  of  the  pack,  after  the  child  is  well  warmed, 
it  may  be  taken  out  with  a  wet  hand  rub.  Infants  do  not  react  well  to 
either  extreme  heat  or  cold.  Fortunately,  however,  they  respond  to  milder 
temperatures  in  as  decided  a  manner  as  adults  do  to  greater  extremes. 

Pleurisy 

There  are  several  forms  of  pleurisy.  Only  the  treatment  of  the  dry  and 
serous  forms  will  be  considered,  since  empyema  of  the  pleura  is  a  surgical 
disease.  In  the  pleurisy  usually  accompanying  pneumonia,  the  inflamma- 
tion is  largely  on  the  side  of  the  visceral  layer.  In  ordinary  pleurisy,  how- 
ever, the  inflammation  involves  chiefly  the  parietal  layer  of  the  pleura. 
The  blood  supply  of  the  two  layers  is  quite  different.  That  of  the  visceral 
layer  is  of  course  from  the  same  blood  vessels  as  the  lung  itself,  while  the 
parietal  layer  is  supplied  by  the  blood  vessels  from  the  intercostal  arteries 
and  with  nerves  from  the  anterior  division  of  the  intercostal.  It  has  been 
shown  that  the  severe,  acute  pain  in  both  peritonitis  and  pleurisy  originate 
in  the  parietal  layer  of  these  membranes.  With  these  facts  in  mind,  it  will 
be  seen  that  the  circulation  and  consequently  the  congestion  of  the  visceral 
layer  will  be  most  readily  influenced  reflexly;  while  with  the  parietal  layer, 
the  circulation  and  congestion  are  influenced  to  a  greater  extent  by  hydro- 
static means,  since  the  blood  vessels  are  connected  directly  with  those  of  the 
superficial  structures. 

For  these  reasons,  while  cold  decreases  reflexly  the  congestion  in  the 
lungs,  it  increases  the  congestion  of  pleurisy.  In  acute  pleurisy,  cold  appli- 
cations greatly  increase  the  pain  and,  if  used  persistently,  may  so  prolong 
the  inflammation  that  weeks  or  months  are  required  for  its  entire  relief. 

On  the  first  indications  of  pleurisy,  the  patient  should  be  given  a  hot  foot 
bath  for  the  purpose  of  warming  the  feet  and  providing  for  thorough  reac- 
tion to  any  other  treatment  that  may  be  given.  This  also  aids  sweating 
which  helps  to  relieve  internal  congestion.  That  which  is  of  the  most  impor- 
tance is  the  use  of  very  hot  fomentations  applied  over  the  affected  area. 
These  should  be  made  of  thick,  heavy  flannel,  wrung  from  boiling  water 


PERICARDITIS  147 

and  wrapped  in  one  thickness  of  dry  flannel.  No  cold  should  be  applied 
between  fomentations.  From  three  to  five  may  be  necessary  in  order  to 
completely  relieve  the  pain. 

If  one  side  only  is  affected,  these  fomentations  should  be  applied/rom  spine 
to  sternum  and  not  simply  to  the  chest  anteriorly.  Given  in  this  manner, 
the  hot  application  dilates  the  posterior,  lateral  and  anterior  cutaneous 
branches  of  the  intercostal  arteries,  thus  withdrawing  the  blood  from  the 
congested  and  inflamed  pleura.  The  fomentations  to  the  chest  should  be 
followed  by  a  heating  chest  pack.  The  partial  pack,  so  arranged  that  the 
moist  gauze  or  linen  covers  only  the  ^affected  area,  is  better  than  the  full 
pack.  In  the  case  of  thin  persons  or  those  of  low  vitality,  it  is  best  to  use 
the  dry  chest  pack.  In  case  the  moist  chest  pack  is  used,  it  may  be  neces- 
sary to  apply  a  hot  water  bottle  over  the  area  outside  of  the  pack  in  order 
to  warm  it  more  promptly. 

After  two  or  three  treatments  in  which  fomentations  alone  are  used, 
with  possibly  a  cold  compress  after  the  last  one  of  each  series,  the  revul- 
sive compress  should  be  used,  the  cold  compress  being  allowed  to  remain 
until  thoroughly  warm  before  the  second  fomentation  is  applied.  Later, 
alternate  hot  and  cold  by  means  of  fomentations  and  a  cake  of  ice  may  be 
used;  and  when  the  patient  is  convalescing,  the  alternate  hot  and  cold  spray 
douche  to  the  back,  front  and  sides  of  the  chest  gives  excellent  results. 
Percussion  or  force  should  not  be  used  in  this  treatment  since  the  vibration 
occasioned  by  it  tends  to  increase  the  effusion.  Neither  should  any  massage 
or  percussion  be  given  to  the  chest  in  concluding  a  treatment.  Even  the 
vibration  of  a  vehicle,  such  as  a  street  car,  may  cause  the  return  of  a  pleurisy 
which  has  nearly  recovered,  and  the  temperature  rise  two  degrees  or  more 
in  a  single  hour. 

If  this  treatment  is  used  from  the  beginning,  that  is  fomentations  and 
later  the  revulsive  compress  and  hot  and  cold,  tapping  for  excessive  effu- 
sions will  be  less  frequently  necessary.  The  ice  bag  to  the  chest  should 
not  be  used  in  any  stage  of  pleurisy.  The  alternate  hot  and  cold  douche  to 
the  feet,  or  the  alternate  hot  and  cold  foot  bath  should  replace  the  hot  foot 
bath  while  the  patient  is  convalescing.  This  helps  to  steady  the  circulation 
and  render  exposure  to  cold  much  less  dangerous. 

Pericarditis 

The  conditions  in  pericarditis,  while  very  similar  to  those  in  pleurisy,  must 
be  treated  upon  somewhat  different  principles,  because  of  differing  anatomi- 
cal relations.  While  the  lung  may,  to  a  certain  extent,  be  immobilized  or 
restricted  in  amplitude  of  movement,  this  is  impossible  in  the  case  of  the 
heart.  All  that  can  be  hoped  in  this  line  is  to  decrease  the  frequency  of  its 
beat.  This  is  admirably  accomplished  by  the  use  of  the  ice  bag  over  the 
heart  and  especially  by  the  frequent  use  of  the  cold  mitten  friction.  The 
latter  is  perhaps  the  more  rational  measure  since  by  its  stimulation  of  the 
peripheral  vessels,  it  relieves  the  heart  of  its  excessive  burden.  The  circu- 
lation of  the  parietal  layer  of  the  pericardium  is  more  or  less  connected  with 
the  surface  blood  vessels,  so  that  the  inflammation  may  be  reduced  in  the 
same  manner  as  with  pleurisy.  Since  fomentations  over  the  heart  increase 


148  THE  TREATMENT  OF  INFLAMMATIONS 

its  rate  and  decrease  its  force  through  reflex  action,  it  is  not  possible  to 
apply  them  as  we  do  in  pleurisy.  The  best  results  may  be  obtained  by  the 
use  of  the  ice  bag  applied  directly  over  the  heart,  while  a  very  large  fomen- 
tation is  so  arranged  as  to  cover  it  and  a  much  larger  area  around  the  heart. 
The  heat  produces  derivation,  while  the  ice  bag  slows  the  heart  rate.  Three 
of  these  fomentations  may  be  given  at  one  time  and  the  treatment  followed 
by  the  heating  compress;  or  the  ice  bag  may  be  left  on  between  treatments, 
being  removed  frequently  enough  to  preserve  the  reflex  excitability  of  the 
nerves.  During  the  course  of  pericarditis,  the  cold  mitten  friction  should 
be  used  one  to  three  times  a  day,  depending  upon  the  degree  of  the  heart 
embarrassment. 

In  the  later  stages,  the  revulsive  compress  to  the  entire  front  of  the 
chest  should  be  used  to  promote  absorption.  Other  treatments  that  are  of 
advantage  are  the  hot  and  cold  foot  bath  after  the  first  few  days,  also  hot 
and  cold  to  the  spine  and  cold  towel  rub.  It  is  not  necessary  to  do  para- 
centesis  unless,  by  accumulation  of  fluid,  the  heart  is  seriously  interfered 
with. 

Myocarditis 

This  is  very  frequently  met  with  in  diphtheria.  Since  the  introduction  of 
antitoxine  it  is,  of  course,  less  frequent  and  less  serious.  Myocardial  degen- 
eration and  consequent  asthenia  are  due  to  the  diphtheria  toxine.  It  may 
not  become  apparent  until  convalescence.  That  which  is  of  most  impor- 
tance is  absolute  rest.  The  ice  bag  to  the  precordia  should  be  kept  in  place 
a  good  deal  of  the  time.  This  slows  the  heart  rate  and  increases  its  force 
without  overstraining  the  cardiac  muscle.  The  cold  mitten  friction  decreases 
the  work  required  of  the  heart  itself.  Both  the  cold  mitten  friction  and  the 
ice  bag  decrease  the  heart  rate  and  increase  its  force.  Digitalis  and  strych- 
nin are  exceedingly  dangerous  in  this  condition  and  should  never  be  used, 
since  by  extreme  stimulation,  they  compel  the  heart  to  overexert  itself. 
Great  depression  results  from  their  use. 

Rheumatic  Fever 

An  acute,  infectious  disease,  primarily  an  inflammation  of  the  synovial 
membranes  and  periarticular  tissues,  with  a  special  tendency  to  involvement 
of  other  serous  membranes,  the  endocardium,  pericardium,  pleura  and  some- 
times the  meninges.  A  more  severe  infection  may  be  complicated  by  myo- 
carditis. In  ordinary  cases,  the  fever  is  moderate,  102.5°  to  103.5°,  but  it 
may  be  very  high. 

Indications  of  first  importance  are  (1)  reduction  and  control  of  the  inflam- 
matory process  in  the  joints;  (2)  prevention  and  treatment  of  complications, 
chiefly  endocarditis;  (3)  relief  of  the  pain.  Formerly  synovitis  was  met 
principally  by  hot  applications,  heating  compresses,  counter  irritation  com- 
bined with  anodyne  mixtures  for  the  relief  of  pain.  The  local  applications 
which  have  proven  helpful  are  fomentations,  the  dry  pack  or  heating  pack 
to  the  joint  and  the  local  electric  light.  They  should  be  continued  until  a 
decided  hyperemia  of  the  skin  is  produced.  After  rubbing  the  part  with 
oil  of  wintergreen  a  local  heating  pack  may  be  applied  and  allowed  to  remain 
until  the  next  treatment.  The  pain  in  the  joints  is  greatly  relieved  by 


RHEUMATIC  FEVER  149 

these  measures.  The  internal  administration  of  the  natural  oil  of  winter- 
green  in  20  minim  doses  every  two  hours  also  adds  to  the  comfort  of  the 
patient  and  seems  to  shorten  the  course  of  the  inflammation.  We  have 
never  seen  any  harmful  results  from  its  use. 

Hot  applications  frequently  fail  to  produce  the  best  results.  Where  con- 
tinuous cold  to  the  joints  has  been  tried,  in  some  cases  it  has  been  found  to 
give  better  results  than  hot  applications.  The  joint  should  be  well  covered 
with  a  thick  flannel  cloth,  outside  of  which  should  be  packed  cracked  ice  or 
snow.  This  should  be  left  in  place  until  the  part  becomes  almost  numb, 
care  being  taken  that  actual  freezing  does  not  occur.  At  the  same  time, 
the  warmth  of  the  body  should  be  sustained  by  hot  water  bottles,  the  foot 
bath,  or  fomentations  to  other  parts.  When  the  pack  has  been  in  place  a 
sufficient  length  of  time  to  do  away  with  tenderness,  it  may  be  removed  and 
and  the  skin  rubbed  thoroughly  with  the  dry  hand  or  snow  until  it  is  red. 
The  ice  pack  should  then  be  replaced.  The  rubbing  -must  be  repeated  at 
intervals  to  promote  reaction  and  prevent  freezing.  If  thought  necessary, 
this  opportunity  may  be  taken  to  mobilize  the  joint.  Two  or  three  joints 
may  be  treated  in  this  manner  at  the  same  time.  When  these  extreme  cold 
applications  are  used,  the  inflammation  seems  to  run  a  much  shorter  course. 
Where  moderate  movement  of  the  patient  is  not  objectionable,  the  use  of 
alternate  extreme  hot  and  cold  immersion  to  the  hands  and  wrists  or  feet 
and  ankles  is  one  of  the  best  measures  for  controlling  the  pain  and  inflam- 
mation in  these  joints. 

The  patient's  general  vitality  should  be  sustained  by  cold  mitten  frictions, 
hot  and  cold  to  the  spine,  and  the  heart  steadied  by  the  use  of  the  ice  bag 
and  cold  mitten  friction.  Fomentations  to  the  chest  may  be  used  every 
four  or  five  hours,  or  of tener  if  necessary,  in  order  to  renew  the  reflex  activ- 
ity where  the  ice  bag  is  used  for  a  considerable  length  of  time.  Free  water 
drinking  should  be  encouraged.  An  actual  sweating  treatment  is  beneficial 
and  may  be  employed  daily  or  two  or  three  times  a  week.  Both  of  these 
measures  favor  elimination  of  toxines.  If  this  plan  of  treatment  is  thor- 
oughly carried  out,  endocarditis  is  less  likely  to  occur. 

Endocarditis.  Should  the  valvular  endocardium  become  involved,  it  is 
necessary  to  keep  the  patient  at  perfect  rest,  both  during  the  course  of 
the  fever  and  fora  considerable  time  after.  The  ice  bag  to  the  heart  should 
be  used  intermittently,  that  is,  being  put  on  for  ten  or  fifteen  minutes  and 
left  off  for  ten  minutes,  or  even  allowing  it  to  remain  in  place  for  a  longer 
time,  depending  upon  the  results  produced.  Buxbaum  6  and  Laqueur  " 
recommend  the  use  of  the  cold  coil  to  the  precordia  two  or  three  times  daily 
for  a  half  hour  to  an  hour,  or  even  longer  at  a  time. 

Cold  mitten  frictions  should  be  given  from  one  to  three  times  daily,  hot 
foot  baths  being  used  as  frequently  as  necessary.  It  is  needless  to  say  that 
the  heart  should  be  examined  daily,  the  findings  being  compared  with  the 
clinical  manifestations.  After  the  fever  has  subsided,  the  patient  must  be 
carefully  guarded  from  all  exposure  to  cold  and  damp.  He  should  return  to 
an  active  condition  very  gradually,  rest  in  bed  being  kept  up  until  the  pulse 

6  Lehrbuch  der  Hydrotherapie,  1903,  p.  234, 

7  Die  Praxis  der  Hydrotherapie,  1910,  p.  143. 


150 

rate  is  nearly  normal.  The  wheel  chair  may  be  used  from  this  point,  but 
before  further  advancement  may  be  made,  the  pulse  rate  must  again  return  to 
normal.  The  patient  may  then  be  allowed  to  lounge  about,  being  dressed 
and  around  the  room  part  of  the  time.  Walking  should  not  be  allowed  if 
the  pulse  rises  above  90.  During  all  this  time,  such  tonic  measures  as  hot ' 
and  cold  to  the  spine,  the  cold  mitten  friction  and  cold  towel  rub  should  be 
used.  After  the  subsidence  of  the  fever,  gentle  massage  may  be  permitted. 
The  resistant  movements  of  the  Schott  method,  and  the  effervescent  bath 
should  not  be  given  until  well  into  convalescence;  that  is,  after  the  fever 
has  been  normal  for  a  month  or  two.  From  this  on,  the  treatment  is  essen- 
tially that  of  chronic  endocarditis  (q.  v.). 

Meningitis 

In  acute  cerebro-spinal  meningitis,  there  is  a  purulent  exudate  covering 
the  convex  dorsal  surfaces  of  the  brain  between  the  dura  mater  and  the 
leptomeninges  filling  the  meshes  of  the  arachnoid  and  extending  downward 
along  the  cord.  The  meninges  of  the  brain  are  intensely  congested. 
The  intracranial  pressure  is  increased.  Quincke's  lumbar  puncture  should 
be  used  for  diagnosis  and  treatment.  The  most  important  treatment  is  the 
use  of  Flexner's  serum,  which  has  given  75  per  cent  of  recoveries  in  400 
cases.  The  most  commonly  employed  hydrotherapeutic  applications  are  the 
ice  cap  and  spinal  ice  bag  applied  continuously,  or  with  but  little  interruption. 
The  spinal  ice  bag  should  be  filled  with  finely  pounded  ice  and  placed  along 
the  cervical  and  upper  dorsal  spine.  Another  smaller  ice  bag  should  be 
placed  crosswise  of  the  neck  at  the  base  of  the  brain.  The  ice  cap  or 
helmet  should  cover  as  large  an  area  as  possible  of  the  convex  surface  and 
sides  of  the  cranium.  These  applications,  though  extensive  and  extreme, 
do  not  usually  cause  chilling.  It  will  be  found  helpful  to  apply  heat  to  the 
extremities  at  intervals.  The  hot  foot  bath,  hot  leg  pack,  or  large  fomen- 
tations to  the  limbs  and  abdomen,  may  be  used.  They  assist  the  action  of 
the  ice  bags  in  reducing  cerebral  congestion.  The  ice  bags  and  ice  cap  may 
conveniently  be  replaced  by  cold  coils  through  which  ice  water  is  flowing. 

Rohrer  reports  a  number  of  cases  in  which  cold  affusions  to  the  head  and 
neck  were  of  great  service  in  relieving  or  mitigating  the  severity  of  cere- 
bral symptoms  and  bringing  about  a  successful  termination.  He  also 
advises  the  cold  affusion  for  the  relief  of  cerebral  symptoms,  whether  delir- 
ium or  coma,  accompanying  infectious  diseases  such  as  pneumonia,  acute 
meningitis  and  in  sunstroke,  neoplasms  and  tubercular  meningitis.  When 
made  very  cold  and  much  prolonged,  they  are  decidedly  antipyretic. 

The  tonic  spasms,  opisthotonos,  and  muscular  rigidity  are  best  met  by  the 
use  of  the  full  warm  bath  given  at  a  temperature  of  98°  to  102°  F.  These 
rnay  be  continued  from  ten  or  fifteen  minutes  to  an  hour,  according  to  the 
needs  of  the  cases.  The  restlessness,  delirium  and  headache  are  often 
entirely  relieved.  The  rigidity  of  the  spine  and  abdominal  muscles  is  favor- 
ably influenced.  We  have  seen  coma  give  way  to  a  fairly  clear  sensorium, 
following  the  bath.  Where  the  temperature  of  the  patient  is  above  102°,  the 
ice  bag  should  be  kept  at  the  base  of  the  brain  and  a  cold  compress  to 
the  head  during  the  bath.  This  is  especially  necessary  in  the  epidemic  form 


APPENDICITIS  151 

of  cerebro-spinal  meningitis.  In  tuberculous  meningitis  it  may  not  be 
needed.  Aufrecht,  Waroschilsky,  Wollisch,  Netter  and  others  report  favor- 
able results  from  the  full  warm  bath.  Rogansky  reports  among  51  cases 
in  women  where  the  warm  bath  was  used,  a  mortality  of  33  per  cent;  and 
among  50  cases  where  the  bath  was  not  used,  a  mortality  of  80  per  cent. 
The  warm  bath  acts  as  a  relaxing  and  sedative  agent.  It  also  aids  in  deplet- 
ing the  cerebral  and  spinal  circulation  and  serves  as  a  tonic  to  the  circula- 
tory system.  Excitant  and  stimulating  measures  should  be  avoided. 

Biliary  Inflammations 

Cholecystitis,  Cholangitis,  Catarrhal  Jaundice,  Subacute  Pancreatitis 

Inflammatory  states  in  these  ducts  and  organs  are  quite  likely  to  be  fol- 
lowed by  conditions  that  require  operative  interference;  but  if  taken  early, 
the  milder  inflammations  subside  under  proper  treatment.  In  cases  of  sub- 
acute  pancreatitis  and  catarrhal  inflammation  of  the  gall  bladder  and  ducts, 
we  have  found  the  following  method  successful:  Once  or  twice  daily  there 
should  be  given  a  treatment  consisting  of  a  hot  footbath  with  fomentations 
to  the  abdomen  and  concluded  by  the  cold  mitten  friction.  The  hot  foot  bath 
and  fomentations  produce  effectual  derivation,  while  the  latter  application 
relieves  the  pain  and  relaxes  the  musculature  of  the  ducts  and  the  gall 
bladder.  The  cold  mitten  friction  is  given  for  tonic  purposes,  to  increase 
leucocytosis  and  combat  infection.  Fomentations  and  hot  and  cold  to  the 
spine  are  useful  for  sedative  and  tonic  purposes.  As  the  patient  improves, 
the  revulsive  compress  to  the  abdomen  may  be  used,  also  the  graduated 
shower,  hot  and  cold  spray  and  the  alternate  douche.  Once  a  week  a  short 
electric  light  hath  shouW  be  given. 

From  the  beginning  of  the  inflammation,  the  patient  should  wear  some 
form  of  heating  compress  to  the  abdomen.  This  is  most  conveniently  ap- 
plied by  means  of  the  moist  abdominal  girdle.  Continuous  cold  appli- 
cations to  the  abdomen  should  not  be  used  in  these  conditions.  In  case  of 
empyema  of  the  gall  bladder,  should  the  patient  refuse  operation  or  a  brief 
delay  seem  advisable,  the  same  plan  should  be  followed.  It  is  impossible  to 
use  the  ice  bag  in  such  a  condition,  since  it  tends  to  cause  firm  contraction 
of  the  muscular  coat  and  might  occasion  rupture  of  the  gall  bladder.  In 
fact  it  is  a  principle  which  should  be  quite  generally  followed  that  inflam- 
mations of  the  hollow  viscera  are  best  treated  by  hot  applications.  This  is 
also  true  of  the  urinary  bladder.  The  spasm  of  the  muscles  occasioned  by 
the  inflammation  is  relaxed  and  the  congestion  decreased. 

Catarrhal  jaundice  in  about  60  per  cent  of  cases  is  now  considered  to  be  due 
to  the  induration  in  the  head  of  the  pancreas  occasioned  by  a  subacute  inflam- 
mation. Outside  of  the  dietetic  treatment  of  this  condition  and  the  special 
necessity  for  free  bowel  movement,  it  should  be  treated  on  the  same  general 
principles. 

Appendicitis 

As  we  have  previously  remarked,  this  is  a  surgical  disease  and  should  be 
surgically  treated  in  practically  all  cases.  Hydrotherapy  produces  such 


152  THE  TREATMENT  OF  INFLAMMATIONS 

marvelous  results  in  the  relief  of  pain  and,  in  many  cases,  safe  conduct  to 
the  interval  that  it  might  almost  seem  to  be  a  specific.  This  temporary 
relief,  however,  can  not  be  depended  upon  for  permanent  cure.  Should  it 
seem  advisable  to  delay  operation  to  the  interval  or,  in  case  the  patient 
refuses  operation,  hydrotherapy  offers  the  best  chances  for  immediate 
recovery. 

The  patient  should  be  given  a  hot  hip  and  leg  pack  with  an  ice  bag  inserted 
under  the  edge  of  the  blanket  just  over  the  appendix.  By  means  of  the 
combined  effect  of  the  hot,  in  drawing  the  blood  from  the  inflamed  part,  and 
the  ice  bag,  in  causing  contraction  of  the  vessels  reflexly,  the  most  effectual 
derivation  is  secured.  The  pain  is  almost  instantly  relieved  in  those  cases  in 
which  the  inflammation  has  not  produced  rupture  of  the  appendix.  After 
twenty  or  thirty  minutes  in  the  pack,  it  should  be  removed  and  a  vigorous 
cold  mitten  friction  be  given  to  all  parts  included  by  it,  except  the  abdomen. 
This  serves  to  fix  the  blood  in  the  skin  and  so  make  derivation  more  per- 
manent. Following  this  treatment,  the  heating  compress  may  be  applied  to 
the  lower  abdomen.  The  hip  and  leg  pack  with  ice  bag  should  be  repeated 
as  often  as  necessary  to  relieve  the  pain  and  make  the  patient  comfortable. 
It  is  perhaps  needless  to  say  that  the  treatment  should  be  preceded  by  a 
thorough  enema.  Cathartics  should  be  avoided.  A  very  large  fomentation 
with  an  ice  bag  under  the  center  over  the  appendix  may  be  substituted  for 
the  pack.  After  the  temperature  has  become  normal  and  the  acute  tender- 
ness has  subsided,  the  patient  should  be  given  general  tonic  treatments, 
always  avoiding  extreme  measures  to  the  abdomen  or  about  the  appendix, 
since  excitation  of  peristalsis  may  cause  return  of  the  inflammation,  or  rup- 
ture of  the  appendix.  In  chronic  appendicitis  the  fomentation  to  the 
abdomen  is  best  calculated  to  relieve  the  pain  and  tenderness.  Where  pos- 
sible, these  cases  should  be  operated  in  the  interval. 

Pelvic  Inflammations 

'  Acute  Endometritis  from  Puerperal  Sepsis,  Salpingitis,  Ovaritis, 
Pelvic  ( Vllulilis  and  Peritonitis 

It  is  necessary  to  differentiate  between  these  conditions,  although  hydri- 
atic  treatment  is  carried  out  along  much  the  same  line  in  all.  IH  the  case 
of  retained  secundines  following  labor  or  abortion,  it  is  imperative  to  per- 
form curettage  as  early  as  possible.  In  the  case  of  simple  salpingitis,  opera- 
ation  should  not  be  done  at  all.  Should  the  inflammation  go  on  to  the  for- 
mation of  a  pyosalpinx,  operation  should  be  delayed  until  the  temperature 
is  normal  and  the  acute  inflammation  has  subsided.  In  pelvic  cellulitis  opera- 
tion is  unnecessary  and  dangerous.  Should  abscess  formation  occur,  either 
in  the  cellular  tissue  or  in  the  peritoneal  cavity,  drainage  should  be  provided. 

With  these  different  conditions  in  mind  and  the  possible  outcome  of  each, 
the  inflammation  should  be  treated  in  the  same  manner  as  that  outlined  for 
appendicitis.  The  patient  may  be  given  the  hot  leg  pack  or  hip  and  leg 
pack,  with  the  ice  bag  applied  to  the  groin,  suprapubic  region  or  other  part 
nearest  the  inflamed  organ.  This  should  be  continued  twenty  to  thirty  min- 
utes and  concluded  with  the  cold  mitten  friction.  The  heating  compress 


MUCOUS  COLITIS  153 

may  be  applied  or,  if  it  seems  wise,  in  some  cases  the  ice  bag  may  be  left 
in  place.  In  other  cases,  fomentations  to  the  lower  abdomen  may  be  given 
every  two  hours.  The  hip  and  leg  pack  with  the  ice  bag,  followed  by  the 
cold  mitten  friction,  should  be  repeated  two  or  three  times  daily  according 
to  the  necessities  of  the  case.  It  is  well,  in  nearly  all  of  these  inflamma- 
tions, to  precede  the  pack  by  very  hot  vaginal  irrigation.  As  the  acuteness 
of  the  inflammation  subsides,  the  revulsive  compress  and  other  alternate 
hot  and  cold  applications  may  be  used.  Perhaps  the  most  effectual  means 
of  treating  chronic  pelvic  inflammations  is  found  in  the  sitz  bath.  When  it 
is  considered  safe  to  allow  the  patient  to  begin  to  walk,  the  hot  sitz  or 
revulsive  sitz  may  be  used.  The  temperature  of  the  bath  should  be  grad- 
ually lowered  until  the  patient  is  taking  a  hot  sitz  followed  by  a  brief  appli- 
cation of  cold  or  very  cold  water.  The  hot  half  bath  is  an  effectual  means 
of  applying  the  principles  of  the  sitz  bath.  In  some  cases,  it  is  to  be  pre- 
ferred. The  body  is  less  cramped  and  both  the  limbs  and  hips  are  entirely 
immersed  in  the  water.  At  the  conclusion,  the  patient  should  receive  a 
cold  pail  pour  to  the  hips.  It  is  not  necessary  to  use  the  extreme,  or  pro- 
longed cold  sitz  in  the  conditions  mentioned  above.  In  place  of  this,  the 
patient  should  be  given  alternate  douches  to  the  sacrum,  feet  and  legs. 
Other  tonic  measures  should  form  part  of  the  course  of  treatment.  The 
cold  rubbing  sitz  is  beneficial  in  delayed  resolution.  Hot  vaginal  irrigation 
or  alternate  hot  and  cold  irrigation  should  be  used  until  resolution  is  com- 
plete. 

Phlebitis 

During  the  early  stages  of  phlebitis,  the  cold  compress  or  ice  bag  should 
be  used  over  the  femoral  vein.  At  the  same  time,  the  limb  must  be  ele- 
vated and  kept  warm.  All  massage  movements  are  strictly  counter-indicated 
in  this  condition.  After  the  first  day  or  so,  fomentations  should  be  used 
frequently,  the  ice  bag  or  cold  compress  being  left  in  place  between  fomen- 
tations. While  the  patient  is  recovering,  that  is,  after  the  temperature 
becomes  normal  and  all  signs  of  acute  inflammation  have  subsided,  the 
revulsive  compress  may  be  used.  The  edema  should  be  treated  by  eleva- 
tion and  such  alternate  hot  and  cold  measures  as  the  revulsive  compress, 
hot  and  cold  foot  or  leg  bath  and  the  alternate  pour.  When  there  is  no 
longer  danger  from  embolism,  massage  may  be  used,  avoiding,  however,  the 
vein  itself.  Later  on,  when  there  remains  only  the  stasis  and  edema,  the 
most  vigorous  hot  and  cold  measures  such  as  the  alternate  douche,  are  bene- 
ficial. 

Mucous   Colitis 

The  first  object  to  be  accomplished  in  the  treatment  of  mucous  colitis  is 
the  removal  of  the  mucous  cast  covering  the  mucous  membrane.  The 
thorough  removal  of  this  coating  will  be  accompanied  by  more  or  less  pain, 
since  it  leaves  a  raw,  unprotected  surface.  That  which  most  effectually 
removes  the  coating  is  some  form  of  treatment  which  will  produce  a  vigor- 
ous exosmosis.  This  may  be  accomplished  by  the  hypertonic  saline  enema, 
or  the  honey  enema.  In  preparing  the  saline  enema,  about  double  the 


154  THE  TREATMENT  OF  INFLAMMATIONS 

amount  of  salt  should  be  added  as  in  preparing  a  physiologic  salt  solution, 
or  to  each  pint  of  saline  solution  there  may  be  added  a  quarter  of  a  tea- 
spoonful  of  Epsom  salts.  This  tends  to  draw  water  from  the  tissues  because 
of  the  concentration  of  the  solution.  Before  using  the  salt  solution,  the 
bowel  should  be  thoroughly  cleansed,  if  necessary  by  both  low  and  high  ene- 
mata;  after  which  the  salt  solution  is  introduced  by  means  of  the  high  bowel 
catheter,  or  by  the  ordinary  enema  given  in  the  knee-chest  position.  A 
pint  or  even  a  quart  of  the  solution  may  be  used  at  one  time.  It  should  be 
retained  as  long  as  possible,  20  to  30  minutes  is  sufficient.  Owing  to  the 
cathartic  action,  it  can  not  be  retained  long.  It  usually  brings  away  with 
it  considerable  of  the  tenacious  mucus,  often  in  cast  form.  The  pain  and 
tenderness  occasioned  by  the  enema  may  be  relieved  by  fomentations  to  the 
abdomen,  and  the  weakness  induced  by  such  drastic  measures  somewhat 
relieved  by  the  cold  mitten  friction. 

The  enema  should  be  repeated  about  three  times  a  week  and  continued 
until  there  is  little  or  no  mucus  brought  away  with  the  passage  of  the  salt 
solution. 

The  molasses  or  molasses  and  soap  suds  enema  may  be  substituted  for  the 
concentrate  salt  solution.  If  given,  it  is  necessary  to  warm  it  slightly  so 
that  it  may  pass  readily  through  the  colon  tube.  From  3  to  6  weeks  of  such 
treatment  may  be  necessary  in  order  to  thoroughly  rid  the  bowel  of  the 
mucus  coating.  After  this,  the  enemata  should  be  entirely  discontinued, 
the  patient  being  given  general  tonic  treatment,  including  fomentations  to 
the  abdomen.  The  following  plan  will  be  found  helpful:  In  the  morning  a 
treatment  consisting  of  a  hot  foot  bath,  fomentations  to  the  abdomen  and 
a  cold  mitten  friction.  The  revulsive  compress  to  the  abdomen  may  also  be 
used.  In  the  afternoon,  hot  and  cold  to  the  spine  followed  by  a  cold  towel 
rub  or  general  massage,  avoiding  the  abdomen.  The  patient  rapidly  regains 
the  weight  and  strength  lost  during  the  first  part  of  the  treatment  and  after 
a  few  weeks  there  is  usually  no  more  mucus  discharged  by  the  bowel. 

Cystitis 

In  the  acute  stage  only  hot  treatment  is  permissible.  These  may  be  given 
by  means  of  a  hot  hip  pack,  fomentations  to  the  lower  abdomen  and  pelvis, 
or  the  hot  sitz  or  revulsive  sitz.  Neither  the  ice  bag  nor  cold  compress 
should  be  used.  Both  of  these  measures  cause  contraction  of  the  bladder 
muscles  and  so  increase  the  pain  arising  from  the  inflamed  mucous  mem- 
brane. The  hot  applications  tend  to  relax  the  musculature  and  draw  blood 
from  the  organ  to  the  surface.  The  patient  should  drink  freely  of  water  in 
order  to  dilute  the  urine,  thus  lessening  its  irritating  qualities.  Regulation 
of  the  diet  is  fully  as  important  as  these  measures. 

In  the  chronic  stage  more  cold  treatment  may  be  used,  such  as  the  revul- 
sive sitz,  graduated  sitz,  hot  and  cold  perineal  spray,  hot  and  cold  rectal 
irrigation,  and  the  alternate  spray  douche  to  the  pelvis.  These  alternate 
applications  may,  at  first,  occasion  some  vesical  spasm,  but  if  persisted  in, 
tend  to  relieve  the  stagnant  circulation.  The  hot  saline  enema  and  continu- 
ous hot  rectal  irrigation  also  produce  good  results.  Bladder  irrigation  with 
hot  physiologic  salt  solution  or  some  mild  antiseptic  as  boric  acid  or  potas- 


SPECIFIC  URETHRITIS  155 

sium  permanganate  should  be  done  once  daily,  rarely  oftener.  This  plan  of 
treatment  is  especially  beneficial  in  those  long  standing  cases  in  which  the 
capacity  of  the  organ  is  very  much  reduced  and  the  walls  have  become 
greatly  thickened  and  indurated. 


Specific  Urethritis,  Vaginitis,  or  Prostatitis 

In  the  acute  stage,  in  addition  to  the  local  medication,  the  ice  bag  should 
be  used  almost  continuously.  The  Leiter  coil  is  an  excellent  means  of  con- 
tinuous cooling.  Some  form  of  internal  cooler  may  be  used.  The  hollow 
prostatic  cooler  whk-h  is  applied  to  the  prostate  through  the  rectum  is  use- 
ful in  decreasing  acute  inflammations  of  that  organ.  Desnos  recommends 
very  hot  (120°  F.)  rectal  irrigation  in  the  acute  stages,  forbidding  it  in  the 
chronic  stage.  We  would  reverse  this  rule,  using  cold  in  the  acute  stage 
and  vigorous  hot  and  cold  in  the  chronic  stage.  As  these  conditions  progress 
toward  the  chronic  stage,  short  hot  applications  should  be  used,  alternating 
with  the  cold,  and  after  the  acute  inflammation  has  subsided,  the  most  vigor- 
ous hot  and  cold  measures  are  necessary.  That  which  is  most  serviceable 
is  the  alternate  hot  and  cold  perinea!  spray.  Chronic  cases  which  have 
resisted  all  sorts  of  medication  very  readily  respond  to  this  measure.  It 
greatly  increases  the  circulation  and  stimulates  local  leucocytosis,  both  of 
which  are  necessary  in  order  to  combat  the  infection  which  frequently 
becomes  cryptic  in  this  stage  and  so  is  beyond  the  reach  of  topical  medica- 
tion. The  graduated  sitz  or  even  the  cold  sitz  may  also  be  used.  In  chronic 
prostatitis  alternate  hot  and  cold  rectal  irrigation  produces  astonishingly 
good  results. 


CHAPTER  XX 
STIMULANTS  AND  TONICS 


There  is  a  decided  difference  in  the  physiologic  effects  of  a  stimulant  and 
a  tonic.  The  idea  that  stimulants  are  necessary  for  tonic  purposes  has  lead 
to  great  confusion  in  the  proper  understanding  of  these  terms.  While  ton- 
ics have  a  wide  range  of  applicability,  the  necessity  for  stimulants  is  much 
more  limited.  We  quote  the  following  from  Sir  William  Broadbent  as  giv- 
ing the  best  idea  of  the  effects  produced  by  stimulants:  "A  falsehood  which 
dies  hard  is  the  idea  that  stimulants  of  whatever  kind  actually  give  strength 
and  are  necessary  for  the  maintenance  of  health  and  vigor.  Such  is  not  the 
case  and  the  well-worn  comparison  that  they  are  the  whip  and  spur,  and  not 
the  corn  and  grass  is  strictly  accurate.  Anything  accomplished  under  the 
influence  of  stimulants  is  done  at  the  expense  of  blood  and  tissue  and,  if 
frequently  repeated,  at  the  expense  of  the  constitution." 

On  the  other  hand,  a  tonic  tends  to  restore  the  body  to  such  a  condition 
that  it  is  better  able  to  perform  its  usual  functions.  It  not  only  "stimu- 
lates" and  hastens  the  normal  expenditure  of  energy,  but  it  also  increases 
the  vital  capacity  of  the  body  for  work.  This  it  does  by  its  action  in  aug- 
menting the  processes  of  anabolism.  It  will  be  seen  from  this  that  the 
whip  can  not  be  a  tonic  since  it  in  no  way  tends  to  restore  an  organ  to  its 
normal  condition  nor  does  it  so  shape  circumstances  that  the  tissues  of  the 
organ  are  built  up.  For  this  reason  strychnin  should  be  considered  a  stim- 
ulant, and  a  stimulant  only.  All  tonic  measures  are  physiologic  in  their 
nature,  while  stimulants  may  or  may  not  be  classed  as  natural  means.  Medi- 
cinal stimulants  produce  an  unnatural  condition  which  in  no  way  tends  to 
restore  to  the  normal.  On  the  contrary,  while  physiologic  stimulants  may 
excite  an  unusual  expenditure  of  energy,  greater  in  this  direction  than  in 
the  building  up  of  the  vitality,  yet  they  do  not  have  the  bad  after  effects 
constantly  observed  following  the  use  of  such  stimulants  as  strychnin. 

In  the  consideration  of  physiologic  means,  we  may  properly  divide 
measures  which  enhance  vital  activity  into  two  classes, — those  which  are 
largely  or  wholly  excitant  and  stimulating,  and  those  which  are  chiefly  tonic 
in  their  effects. 

Hydriatic  Measures  Chiefly  Tonic  in  Nature 

Tonic  effects  are  derived  principally  from  cold  applications.  The  reaction 
to  vigorous  cold  measures  has  been  shown  to  increase  muscular  capacity, 
quicken  the  circulation,  enhance  nerve  activity,  etc.  In  this  sense,  tonic 
effects  may  be  considered  to  be  a  secondary  result  or  reaction  from  the 
primary  stimulation.  Tonic  effects  may  also  be  had  from  alternate  hot  and 


EFFECTS  OF  TONICS  157 

cold  applications,  never  from  hot  alone,  except  they  be  very  short  or  where 
the  heat  of  the  body  is  much  below  par. 

That  the  wide-spread  effects  of  tonic  applications  may  be  fully  realized 
by  the  reader,  we  give  below  a  tabulated  list  of  such  effects.  These  have 
been  discussed  in  detail  in  the  first  part  of  this  work. 

Cold  applications  produce  the  following  tonic  effects: — 

1.  Quicken  the  circulation  of  the  blood  and  lymph. 

2.  Strengthen  the  heart-beat. 

3.  Raise  blood  pressure. 

4.  Increase  glandular  activity. 

5.  Enhance  nerve  activity. 

6.  Augment  assimilation. 

7.  Increase  depth  of  respiration. 

8.  Increase  amount  of  oxygen  absorbed  and  carbon  dioxide  eliminated. 

9.  Leucomaines  are  more  perfectly  oxidized. 

10.  Increase  oxidation  and  metabolism  in  general. 

11.  Stimulate  heat  production. 

12.  Equalize  the  distribution  of  red  and  white  blood  cells,  increasing  their 
number  in  the  peripheral  circulation  and  thereby  preventing  globular  stasis. 

13.  Increase  alkalinity  of  the  blood. 

14.  Augment  the  production  of  agglutinin  and  other  antibodies. 

15.  Stimulate  phagocytosis. 

16.  Increase  muscular  capacity. 

17.  Decrease  fatigue. 

Tonic  measures,  to  a  greater  or  less  extent,  are  indicated  in  all  forms  of 
disease.  In  some  conditions  the  tonic  results  derived  from  measures  whose 
principal  effects  are  other  than  tonic  are  sufficient  to  secure  recovery,  but 
in  nearly  all  diseases  some  special  tonic  treatment  is  needed  and  in  not  a  few, 
this  alone  is  sufficient.  In  the  majority  of  cases,  it  is  necessary  to  begin 
with  the  mildest  of  tonic  measures,  increasing  the  vigorousness  of  the  treat- 
ment as  the  patient  develops  the  ability  to  react. 

The  following  are  the  principal  tonic  measures  in  the  order  of  their  sever- 
ity. Taken  one  after  another,  they  may  be  said  to  constitute  a  therapeutic 
ladder. 

1.  WET  HAND  RUB.     A  few  very  anemic  patients  do  not  possess  sufficient 
vitality  to  react  at  first  to  the  cold  mitten  friction.      These  patients  should 
be  given  a  wet  hand  rub  beginning  with  one  or  two  parts  only,  and  increas- 
ing the  extent  of  the  area  treated  as  the  patient's  reactive  powers  increase. 
At  first,  tepid  or  cold  water  may  tax  the  reactive  powers.    If  so,  the  patient 
must  be  rubbed  vigorously  during  and  following  the  application.      The  tem- 
perature of  the  water  should  be  decreased  daily  2°  or  3°  F.,  until  cold  water 
or  ice  water  is  used.     Usually,  before  this  point  is  reached,  the  cold  mitten 
friction  may  be  employed. 

2.  COLD  MITTEN  FRICTION.     Begin  with  cold  water,  dipping  the  mitten 
once  for  each  part,  and  rubbing  it  vigorously  until  it  is  well  warmed.       It 
should  then  be  dried  and  again  rubbed  with  the  dry  hand.      With  each  suc- 
ceeding treatment  the  temperature  may  be  lowered  and,  in  a  day  or  two, 
the  number  of  times  the  mitten  is  dipped  for  each  part  may  be  increased  to 


158  STIMULANTS  AND  TONICS 

two  and  later  to  three  or  four.      When  the  patient  is  able  to  react  to  ice 
water  used  in  this  manner,  other  more  vigorous  means  may  be  tried. 

3.  COLD  TOWEL  RUB.     This  is  graduated  in  the  same  manner  as  the  cold 
mitten  friction.     Since  the  cold  water  is  applied  to  a  greater  surface  at  one 
time,  it  requires  somewhat  greater  vitality  to  react  to  this  measure. 

4.  PAIL  POUR.     After  the  warm  bath  or  some  other  hot  treatment,  the 
patient  may  receive  to  the  shoulders,  chest  and  back,  2  or  3  pails  of  water 
differing  in  temperature  from  5°  to  15°  F.      The  first  used  should  contain 
water  from  100°  to  105°.      The  second,  from  80°  to  90°,  and  the  third,  from 
65°  to  80°.      As  the  patient  shows  ability  to  react  to  these  measures,  the 
temperature  of  the  water  may  be  decreased  or  additional  pails  used. 

5.  SALT  GLOW.     This  may  be  made  a  mild  or  extreme  measure  accord- 
ing as  fine  or  coarse  salt  is  used,  and  much  or  little  friction  given.    Since  it 
is    not    accompanied    by    cold  water,  it  does  not  severely  tax  the  reactive 
powers.     A  pail  pour  or  shower  may  be  used  to  remove  the  salt  and  so  com- 
bine it  with  other  tonic  measures. 

6.  COLD  DOUCHE.     This  should  be  preceded  by  a  warm  or  hot  shower,  or 
it  may  be  given  as  a  hot  and  cold  douche  consisting  of  three  or  four  changes. 
The  reaction  is  enhanced  by  the  use  of  percussion.      At  first  only  a  limited 
portion  of  the  body  should  be  treated  in  this  manner,  such  as  the  feet  and 
legs,  later  the  spine  and  chest  also. 

7.  WET  SHEET  RUB.     The  patient  should  stand  in  a  tub  of  hot  water. 
At   first  the  sheet  should  be  wrung  nearly  dry  from  cold  water.      This  is 
wrapped  about  the  patient  in  the  manner  directed  under  Technique.      The 
patient  should  be  rubbed  over  the  sheet  until  warm  and  then  quickly  dried 
by  means  of  sheets  and  towels.     Later,  colder  water  should  be  used  arid  the 
sheet  wrung  less  thoroughly. 

8.  DRIPPING  SHEET  RUB.     When  the  patient  has  acquired  the  ability  to 
react  to  the  wet  sheet  rub,  the  treatment  may  be  increased  in  vigor  by  pour- 
ing over  the  shoulders  while  the  patient  is  still  wrapped  in  the  sheet  and 
after  he  has  been  warmed  by  rubbing,  from  1  to  3  pails  of  cold  water,  at 
first  using  one  containing  cool  water  and  later,  2  or  3  pails  of  colder  water. 
After   each   pour,  the  rubbing  should  be  renewed  and  continued  until  the 
patient  is  warm. 

9.  SHALLOW  BATH.    A  full  length  tub  should  be  partly  filled  with  cold 
water.     The  patient  then  enters  the  tub,  sitting  upright  while  both  patient 
and  attendant  rub  the  limbs  and  hips.     The  patient  now  reclines  in  the  tub 
while  he  is  again  rubbed  with  cold  water,  it  being  dashed  up  over  the  body 
during  the  course  of  the  rubbing.     The  water  should  hardly  more  than  half 
cover  the  body.      The  temperature  of  the  shallow  bath  may  be  gradually 
decreased. 

10.  COLD  PLUNGE.  This  measure  may  be  considered  the  last  round  of  the 
ladder.  By  active  swimming  movements,  the  patient  should  promptly  react 
to  a  plunge  in  cold  water  at  80°  to  85°  F.,  and  later,  to  much  lower  tem- 
peratures. The  plunge  bath  should  not  be  continued  long.  At  first,  one  or 
two  minutes  only  are  sufficient.  Later,  five,  ten,  or  even  fifteen  minutes 
may  profitably  be  spent  in  swimming. l 

1     For  more  complete  details  of  these  treatments  see  Technique. 


ANEMIA  -159 

We  have  already  mentioned  that  there  are  a  large  number  of  conditions  in 
which  tonic  measures  are  indicated.  In  some,  however,  it  is  necessary  to 
provide  a  special  course  of  tonic  treatment.  The  following  is  a  partial  list 
of  such  conditions.  A  few  of  these  will  be  considered  somewhat  at  length. 

Indications  for  Special  Tonic  Treatment. 

1.  Anemia. 

2.  Neurasthenia. 

3.  Melancholia  and  hypochondria. 

4.  Hysteria. 

5.  Dyspepsia. 

6.  Insomnia. 

7.  Chronic  inebriety. 

8.  Chronic  articular  rheumatism. 

9.  Valvular  heart  disease  and  obesity  with  fatty  heart. 

10.  Diabetes. 

11.  Cerebral  congestion  due  to  sunstroke. 

12.  Multiple  neuritis  (chronic  stage). 

13.  Locomotor  ataxia. 

14.  Hemiplegia. 

In  the  three  last  conditions  the  treatment  should  partake  more  of  the  nature 
of  a  true  stimulant  as  extreme  measures  are  necessary  to  provoke  activity 
in  atrophied  nerve  structures. 


Anemia 

Under  this  heading  we  include  the  various  forms  of  secondary  anemia. 
Primary,  idiopathic,  or  pernicious  anemia  should  be  treated  along  much  the 
same  lines.  As  far  as  possible,  all  known  causes  should  be  removed.  Irre- 
spective of  the  many  ultimate  causes  of  anemia,  this  state  is  due  to  deficient 
activity  of  the  blood-making  organs  or  increased  rapidity  in  the  destruction 
of  the  red  cells.  There  is  one  factor  that  is  an  almost  constant  accompani- 
ment of  anemia.  This  factor  is  defective  digestion  and  malassimilation. 
Because  of  bad  food,  gastro-intestinal  infections  and  putrefactions,  the 
body  may  be  unable  to  digest  and  appropriate  from  the  food  the  ele- 
ments needed  to  sustain  the  system.  It  is  not  only  the  blood  that  is  defi- 
cient, but  the  entire  system  is  impoverished.  Therefore  one  of  the  chief 
objects  to  be  attained  is  improvement  in  digestion  and  assimilation.  With- 
out this,  all  other  treatment,  no  matter  how  good  in  itself,  will  be  an  almost 
total  failure.  The  body  may  be  given  a  more  than  sufficient  supply  of  iron 
without  the  slightest  effect  unless  the  digestion  and  assimilation  are  improved 
by  appropriate  treatment. 

Artificial  preparations  of  iron  nearly  always  derange  the  digestion  and  so 
lessen  the  absorption  of  all  nutriment,  iron  included.  Preparations  of  iron, 
from  Blaud's  pill  to  the  bad  blood  and  marrow  of  slaughter-house  animals, 
are  all  alike — unnecessary  in  the  treatment  of  anemia.  The  amount  of 
organic  iron  contained  in  ordinary  foods  is  abundantly  sufficient  to  supply 
the  hematogenic  organs  with  the  necessary  amount  for  the  formation  of  the 


160  STIMULANTS  AND  TONICS 

normal  per  cent  of  hemoglobin.  Prof.  G.  von  Bunge  2  tells  us  that  the  yolk 
of  eggs  contains  a  stable  organic  compound  of  iron  with  neuclein  and  that 
this  compound  is  doubtless  a  precursor  of  hemoglobin.  So  efficient  is  this 
in  the  formation  of  hemoglobin  that  he  proposes  to  call  it  the  "blood  former" 
(hematogen) .  We  have  recently  been  assured  that  the  egg  contains  medicinal 
principles,  which  idea  fully  agrees  with  Professor  Bunge's  statement.  The 
fresh  green  vegetables,  fruits,  grains  and  nuts  contain  considerable  amounts 
of  organic  iron.  Asparagus  and  spinach  contain  from  20  to  nearly  40  milli- 
grams of  organic  iron  to  the  100  grams  of  dry  substance.  3  Ten  milligrams 
or  1-6  grain  of  iron,  the  daily  amount  required  by  an  adult  would  be  con- 
tained in  four  ounces  of  the  yolk  of  egg.  Moreover,  this  iron  is  in  a  form 
to  be  most  easily  digested  and  most  fully  absorbed. 

It  is  thus  amply  demonstrated  that  inorganic  or  artificial  preparations  of 
iron  are  not  only  entirely  unnecessary,  but  also  in  many  cases,  positively 
injurious,  since  they  derange  the  digestion.  On  the  other  hand,  the  best 
food,  containing  sufficient  organic  iron,  will  not  suffice  to  cure  anemia  if 
intestinal  putrefaction  continues  and,  through  lack  of  proper  tone  and  cir- 
culation, the  body  is  unable  to  appropriate  the  food  it  receives.  In  addition, 
then,  to  the  necessity  for  a  simple,  natural  diet  and  special  attention 
directed  toward  improving  the  digestion,  there  are  two  other  objects  to  be 
attained.  First,  the  blood-making  organs  must  be  stimulated.  Second,  the 
circulation  must  be  improved.  That  all  these  results  can  be  accomplished 
by  tonic  hydrotherapy  has  been  demonstrated  as  shown  in  the  chapters  on 
the  circulation. 

That  tonic  hydrotherapy  combined  with  a  simple  natural  diet,  outdoor  life, 
fresh  air  and  sunshine  is  far  more  efficient  than  iron,  strychnin,  arsenic,  the 
hypophosphites,  quinin  and  the  like,  is  the  daily  experience  of  those  who 
systematically  employ  physiologic  means.  It  has  yet  to  be  proven 
that  arsenic  has  any  effect  upon  the  blood  but  to  impoverish  it.  That  it 
lessens  both  the  per  cent  of  red  cells  and  of  hemoglobin  when  regularly 
administered  has  been  amply  proven.  In  searching  for  experimental  data 
concerning  any  positive  benefit  that  may  be  derived  from  the  administration 
of  arsenic,  one  is  struck  with  the  paucity  of  evidence  along  this  line.  We 
are  asked  to  rely  upon  very  vague  assumptions,  mostly  empirical  in  nature. 
We  have  frequently  treated  cases  of  profound  anemia  in  which  the  whole 
picture  was  that  of  chronic  arsenic  poisoning  rather  than  simple  anemia, 
the  arsenic  having  been  administered  to  cure  the  anemia. 

In  the  hydriatic  management  of  anemia,  it  is  necessary  to  provide  a  care- 
fully graded  system  of  tonic  treatment.  In  the  extreme  forms  of  anemia, 
the  beginning  must  be  at  the  bottom  round  of  the  ladder  of  tonic  measures. 
Each  application  of  cold  should  be  preceded  by  a  short  hot  application, 
such  as  fomentations  to  the  spine  or  abdomen,  hot  foot  bath,  or  local  electric 
light  bath.  No  long  hot  treatments  should  be  used  since  the  vitality  is  so 
much  reduced  as  to  illy  bear  the  depression  occasioned  by  sweating.  How- 
ever, all  forms  of  local  applications  of  heat  are  indicated  in  anemia.  Follow- 
ing one  or  more  short  moderately  hot  applications,  the  patient  should  be 
given  a  wet  hand  rub,  cold  mitten  friction  or  cold  towel  rub,  according  to 

2  Physiological  and  Pathological  Chemistry,  Second  English  Edition,  p.  375. 

3  Ibid.,  p.  376. 


NEURASTHENIA  161 

his  ability  to  react.  This  should  be  repeated  about  twice  daily,  or  a  light 
massage  may  be  given  once  a  day.  Later  on,  as  the  circulation  improves, 
the  patient  may  be  treated  by  the  cold  towel  rub,  hot  and  cold  to  the  spine, 
and  still  later,  alternate  hot  and  cold  douches  and  sprays.  Advancement  in 
the  tonics  should  be  made  slowly.  It  may  take  several  weeks  for  the  patient 
to  acquire  sufficient  vitality  to  react  to  a  general  shower  bath.  The  salt 
glow  may  be  used  before  the  more  vigorous  cold  applications  can  be  borne. 
Following  this,  may  be  used  the  general  affusion  or  pail  pour,  at  first  of 
warm  or  tepid  water,  later  of  cool  and  cold  water.  After  some  weeks  a 
short  full  electric  light  bath  may  be  given,  followed  by  a  vigorous  hot  and 
cold  spray.  When  this  point  has  been  reached,  advance  may  be  made  more 
rapidily,  using  the  wet  sheet  rub,  dripping  sheet  rub,  cold  shallow  bath  and 
the  cold  plunge. 

Massage  is  especially  indicated  in  anemia  before  the  patient  in  able  to 
take  much  exercise.  The  manipulation  should  be  what  is  termed  "general 
massage;"  i.  e.,  it  should  combine  all  of  the  procedures  usually  given  in 
Swedish  massage.  Of  special  importance  are  the  movements  of  deep  knead- 
ing. After  a  single  massage,  lasting  45  to  60  minutes,  the  red  cells  fre- 
quently show  a  gain  of  25  to  50  per  cent  and  may  even  be  doubled  in  num- 
ber. These  gains  are  of  course  not  permanent  but  they  last  longer  and 
longer  as  the  treatments  are  repeated.  The  hemoglobin  per  cent  rises  more 
slowly  than  the  red  cells. 

Full  sun  baths  are  especially  beneficial.  The  scientific  basis  for  the  use 
of  the  sun  bath  in  anemia  and  chlorosis  has  been  well  demonstrated  experi- 
mentally. 4  Exposure  to  sunlight  increases  the  oxygen-carrying  capacity 
of  the  red  blood  cells.  It  stimulates  hematogenesis,  increasing  both  the 
number  of  red  cells  and  the  hemoglobin  per  cent.  It  is  a  fundamental  proto- 
plasmic stimulant.  It  hastens  cell  division  and  cell  growth.  Pure,  fresh 
air  supplies  the  needed  oxygen  that  makes  possible  the  best  results  from 
the  sunlight.  "Zuntz  and  his  school  have  shown  that  the  effects  of  moun- 
tain air  are  apparent,  not  only  in  their  influence  on  red  corpuscles,  but  also 
on  the  nitrogenous  metabolism  of  the  body  as  a  whole,  so  that  there  is  in 
most  individuals  a  positive  nitrogen  balance,  an  actual  reproduction  of  the 
conditions  found  in  the  growing  organism."5 

The  effects  of  sunlight  and  out  door  life  among  natural  surroundings  are 
apparent  not  alone  in  the  physical  changes  they  induce,  but  also  in  the  psy- 
chic improvement  of  the  patient.  When  proper  attention  is  given  to  all 
of  the  items  mentioned,  also  to  digestion  (see  Dyspepsia)  the  maximum 
good  may  be  obtained. 


Neurasthenia 

The  management  of  neurasthenia  by  systematic  hydrotherapy  has  been 
so  universally  successful  that  it  is  now  regarded  by  neurologists  as  indespens- 
able  in  the  treatment  of  this  condition.  Moreover,  the  necessity  for  change 
of  environment  and  efficient  training  of  the  patient  in  proper  habits  of  diet, 

4  Cleaves— Light  Energy,  pp.  271,  322. 

5  Starling — Fluids  of  the  Body,  p.  142. 


162  STIMULANTS  AND   TONICS 

rest,  exercise,  etc.,  demand  that  for  a  time,  at  least,  this  be  carried  on  in  an 
institution  fully  equipped  with  the  necessary  appliances  and  manned  with 
physicians  and  attendants  trained  in  hydriatic  technique. 

The  manifestations  of  nerve  exhaustion  are  exceedingly  protean.  For 
this  reason,  individualization  is  perhaps  more  imperative  in  this  than  in  any 
other  disorder.  It  is  necessary  to  carefully  observe  the  effects  of  each 
treatment.  While  the  statements  of  the  patient  in  regard  to  these  are  not 
a  sufficient  guide,  they  should  not  be  wholly  disregarded.  It  may  be  neces- 
sary to  make  several  changes  before  the  most  suitable  means  has  been  set- 
tled upon.  A  mere  education  in  technique  is  not  all  that  is  necessary  for 
the  physician  to  understand.  He  should  be  thoroughly  conversant  with  the 
scientific  basis  of  physiologic  effects,  by  close  observation  adapting  these  to 
the  needs  of  the  patient  as  experience  shall  direct. 

The  psychic  element  plays  such  a  large  part  that,  in  case  the  patient 
takes  a  violent  dislike  to  some  procedure,  not  absolutely  essential,  it  is  best 
to  substitute  another  of  similar  effect.  We  commonly  encounter  the  idea 
that  frequent  baths  are  weakening.  It  is  no  small  task  to  disabuse  the 
mind  of  this.  This  and  other  imagined  dangers  are  very  real  to  the  mind  of 
the  patient.  Often,  they  may  be  overcome  by  utilizing  some  other  notion 
as  a  placebo.  We  have,  however,  found  straight-forward  education  the 
best  all-around  plan.  This  requires  a  great  deal  of  time  on  the  part  of  the 
physician,  but  the  efforts  are  often  well  repaid  in  the  long  run. 

The  neurasthenic  state  is  almost  invariably  associated  with  faulty  diges- 
tion. The  digestive  derangement  may  be  a  large  cause,  a  contributing  factor 
or  a  result  of  the  nerve  exhaustion.  Where  defective  digestion  is  a  promi- 
nent feature,  special  measures  should  be  directed  toward  restoration  of  the 
normal  function.  The  treatment  of  dyspepsia  is  considered  in  another 
place. 

The  overworking  of  any  organ  or  function  leads  to  exhaustion.  The  chief 
cause  of  nerve  exhaustion  lies  in  overactivity  of  the  brain  and  nerves,  accom- 
panying deficient  physical  activity.  Neurasthenia  may,  however,  occur  in 
an  individual  who  is  engaged  in  an  accupation  requiring  constant  bodily 
activity.  Worry,  grief,  disappointment — financial  or  social,  these  all  have 
their  place  in  the  causation  of  nerve  exhaustion.  A  comprehensive  view 
of  the  disease  and  its  causes  reveals  the  necessity  for  two  classes  of  phy- 
siologic effects,  viz, — tonic  and  sedative.  Sedative,  to  assist  in  securing 
rest,  the  most  essential  element  in  building  up  lost  nerve  force.  Tonic,  to 
restore  normal  nerve  activity  and  hasten  the  building  up  process.  No  hard 
and  fast  lines  may,  however,  be  drawn  between  procedures  directed  to  these 
ends.  Tonic  measures  are,  of  course,  in  the  long  run  conducive  to  normal 
rest,  but  they  may  also  be  immediately  sedative  in  their  effects.  This 
peculiar  paradox,  that  tonic  measures  produce  sedation  and  sedative  meas- 
ures are  tonic,  exists  only  in  the  realm  of  physiologic  therapy.  One  would 
not  pick  upon  the  bromides  to  restore  the  normal  nerve  tone  or  upon  strych- 
nin to  produce  rest  or  sleep.  The  special  treatment  of  insomnia  and  the 
irritative  neurasthenic  state  will  be  considered  more  at  length  under  Seda- 
tive Effects  (q.  v.). 

In  beginning  the  treatment  of  a  neurasthenic  patient  it  is  well,  at  first, 
to  test  the  reactive  powers  by  mild  measures  which  will  produce  no  shock. 


NEURASTHENIA  163 

Since  first  impressions  are  often  very  lasting,  the  initial  treatment  may  con- 
sist of  such  forms  of  the  bath  as  are  not  greatly  different  from  those  used 
at  h  >me.  This  serves  to  make  the  patient  acquainted  with  the  attendant 
and  the  attendant  with  some  of  the  peculiarities  of  the  patient.  The  full 
warm  tub  bath  and  tub  shampoo,  finished  with  a  warm  and  then  a  cool  pail 
pour  serves  this  purpose  for  a  large  number  of  patients.  Since  nearly  all 
neurasthenics  complain  of  cold -feet  and  more  or  less  abdominal  distress,  we 
frequently  use  the  hot  foot  bath  with  fomentations  to  the  abdomen.  This 
may  be  made  the  second  treatment  and  concluded  with  a  wet  hand  rub  or 
cold  mitten  friction.  With  this,  or  following  closely,  we  utilize  hot  and  cold 
to  the  spine,  the  revulsive  compress,  the  pail  pour,  salt  glow  and  graduated 
spray.  Later,  after  considerable  reactive  capacity  has  been  developed,  the 
cold  towel  rub  and  wet  sheet  rub  may  be  used.  The  alternate  spray,  alter- 
nate douche  and  shallow  bath  are  quite  vigorous  means  and  should  not  be 
ventured  upon  in  the  agitative  form  of  neurasthenia  or  not  until  milder 
tonics  have  been  used  for  some  time. 

The  wet  sheet  pack,  although  an  excellent  tonic,  as  well  as  sedative  means, 
is  often  objected  to  by  the  neurasthenic.  He  complains  that  it  makes  him 
nervous,  he  feels  restrained,  etc.  The  sitz  bath  at  the  various  temperatures 
at  which  it  may  be  used,  is  capable  of  most  excellent  results.  Provided 
there  are  no  local  conditions  requiring  treatment,  the  sitz  tub  may  first  be 
filled  with  water  at  98°  which  is  gradually  raised  to  102°  or  103°  and  then 
lowered  to  90°  or  85°  just  before  the  close,  or  it  may  be  concluded  with  a 
cold  pail  pour  to  the  hips  (revulsive  sitz) .  The  second  bath  may  be  begun  at  98° 
or  95°  and,  without  raising  the  temperature  of  the  water,  gradually  lowered 
to  85°  or  80°.  On  each  succeeding  day,  it  is  begun  at  a  slightly  lower  tem- 
perature and  finished  with  colder  water,  until  it  is  essentially  a  prolonged 
cold  sitz.  The  bath  acts  by  reducing  the  blood  supply  to  the  abdomen  and 
pelvis,  decongesting  the  abdominal  and  pelvic  sympathetics  and  restoring 
their  tone.  It  aids  in  the  relief  of  general  splanchnoptosis. 

About  once  a  week  the  patient  should  be  given  a  short  electric  light  bath 
followed  by  a  spray,  or  shampoo  and  spray.  The  electric  light  bath  should 
be  3  or  4  minutes  in  length,  sufficient  to  thoroughly  warm  the  skin  and  pro- 
duce beginning  perspiration.  » 

The  old  idea  that  the  melancholic  state  is  due  to  liver  derangement  (black 
bile)  is  not  wholly  without  foundation.  Wrong  habits  of  diet,  together  with 
constipation,  are  large  factors  in  the  production  of  the  depressed  type  of 
neurasthenia.  Both  of  these  crowd  the  liver  with  toxins  and  products  of 
imperfect  digestion.  An  overworked  liver  in  time  becomes  a  sluggish,  tor- 
pid liver,  incapable  of  performing  its  functions  as  a  toxin  destroyer  and 
emunctory.  In  addition  to  general  treatment  and  treatment  directed  toward 
the  relief  of  indigestion  and  constipation,  we  have  found  alternate  hot  and 
cold  applications  to  the  hepatic  area  of  special  advantage.  The  revulsive 
compress,  alternate  hot  and  cold,  and  especially  the  alternate  hot  and  cold 
percussion  douche  to  the  liver  should  be  used  frequently. 

For  cerebral  congestion  nothing  is  superior  to  the  alternate  hot  and  cold 
foot  bath  or  the  alternate  percussion  douche  to  the  feet.  The  latter  may  be 
preceded  by  a  short  hot  leg  pack  or  hot  leg  bath  with  cold  compresses  to  the 
head  and  neck. 


164  STIMULANTS  AND  TONICS 

The  work  cure  for  neurasthenia  has  been  successful  in  the  hands  of  a  few  phy- 
sicians who  have  formulated  a  definite  plan  for  such  treatment.  That  which 
has  been  reported  is  largely  in  the  line  of  indoor  work.  Much  more  success- 
ful is  the  use  of  gardening,  floriculture  and  horticulture  to  employ  the  time 
and  occupy  the  thoughts  of  the  neurasthenic  patient.  These  occupa- 
tions take  him  out  into  the  fresh  air  and  sunshine,  and  to  the  extent  he  can 
be  interested  in  "helping  things  grow,"  just  to  that  extent  the  success  of 
the  plan  is  assured. 

It  has  also  been  shown  by  Pansini6  that  the  actinic  rays  of  sunlight  or 
artificial  light  increase  muscular  capacity,  while  red  light  has  the  opposite 
effect.-  Red  light  of  course  consists  largely  of  thermic  frequencies  and 
hence  its  effect  is  essentially  that  of  heat.  Blue  light  (actinic  ray)  increases 
both  the  amplitude  and  number  of  contractions  as  shown  by  ergograms. 

In  a  control  test  the  muscles  were  able  to  lift  1.736  kilograms;  before  re- 
covering from  the  fatigue  of  this  test  they  lifted  1.455  kilograms;  and  after 
exposure  to  the  light  of  a  blue  lamp  the  total  of  the  curve  showed  1.848  kilo- 
grams, indicating  not  only  the  recovery  from  fatigue  but  a  gain  of  .112  kilo- 
grams over  the  capacity  of  the  unfatigued  muscles. 

The  general  program  and  the  distribution  of  the  treatments  during  the 
day  are  of  importance. 

It  will  be  found  that  the  best  results  are  obtained  by  one  tonic  treatment 
a  day.  A  short  sedative  treatment  may  be  given  in  the  afternoon  or  at 
night.  If  more  than  this  is  used,  the  afternoon  treatment  may  consist  of 
massage  or  electricity  in  some  form.  Too  continuous  a  round  of  treatment 
limits  the  time  for  rest  and  out-of-door  life  and  recreation  which  are  all 
important  in  neurasthenia.  It  is  a  mistake  to  allow  the  patient  to  insist 
upon  local  applications  three  or  four  times  a  day  for  local  distresses  such  as 
"backache"  or  "indigestion."  They  only  serve  to  more  firmly  fix  the 
patient's  attention  upon  some  minor  ailment  and  confirm  his  introspective 
tendencies. 

The  measures  and  plan  outlined  above,  when  given  under  careful  super- 
vision and  combined  with  regulation  of  the  diet,  exercise,  rest,  etc.,  will,  if 
proper  psychic  control  be  not  neglected,  invariably  result  in  the  recovery  of 
the  neurasthenic  patient. 


Splanchnic  Neurasthenia 

In  many  neurasthenic  patients  the  distressing  symptoms  center  about  the 
abdomen.  There  is  a  feeling  of  weight  and  exhaustion  accompanied  by 
mental  depression.  The  exacerbations  of  this  state  have  not  inaptly  been 
styled  "the  blues,"  as  the  exciting  causes  are  worry,  disappointment  and 
such  like  nervous  disturbances  which  give  rise  to  a  temporary  melancholia. 
The  predisposing  factors  entering  into  this  condition  are  constipation,  auto- 
intoxication, dyspepsia,  general  nerve  exhaustion,  insufficient  physical  exer- 
cise, etc. 

The  immediate  physical  basis  of  splanchnic  neurasthenia  lies  in  an  engorge- 
ment of  the  splanchnic  blood  vessels,  particularly  of  the  veins.  These  ves- 

6    Cleaves-Light  Energy,  pp.  301  to  303. 


SPLANCHNIC  NEURASTHENIA  165 

sels  are  capable  of  great  distension  when  the  vasomotors  are  rendered  par- 
etic  through  intestinal  autointoxication,  worry,  grief,  etc.  A  very  rational 
plan  of  treatment,  as  far  as  this  condition  is  concerned,  ,is  advised  by 
Abrams. 7  This  consists  of  various  means  intended  to  increase  the  abdomi- 
nal tension  and  stimulate  the  splanchnic  vasomotors  for  the  purpose  of  re- 
lieving the  visceral  stasis  of  blood,  and  by  means  of  a  quickened  splanchnic 
blood  current,  especially  in  the  liver,  directly  increasing  the  hepatic  destruc- 
tion of  poisons  and  hastening  their  elimination. 

Abrams  especially  favors  the  use  of  the  sinusoidal  current  for  this  pur- 
pose. Applied  by  means  of  a  stationary  spinal  electrode  and  a  labile  abdominal 
sponge,  the  treatment  is  certainly  most  effective.  The  abdominal  muscles 
are  powerfully  stimulated  by  the  slow  sinusoidal  current,  thus  increasing 
intra-abdominal  pressure,  but  the  greatest  effect  is  upon  the  splanchnic  vaso- 
motors reflexly. 

These  patients  experience  much  relief  by  assuming  the  horizontal  position. 
The  movement  of  "inspiratory  lifting"  as  carried  out  in  abdominal  massage 
also  affords  instant  relief.  The  use  of  abdominal  supporters  and  the  appli- 
cation of  broad  bands  of  adhesive  plaster  to  the  abdomen  in  splanchnoptosis 
and  splanchnic  neurasthenia  give  relief  as  long  as  they  are  in  place.  Both 
these  means  however,  ultimately  result  in  weakening  the  abdominal  mus- 
cles and  so  unless  accompanied  by  other  treatment  defeat  their  own  pur- 
pose. Where  it  is  at  all  possible  to  strengthen  the  abdominal  muscles,  it 
is  better  to  adopt  some  system  of  exercises  especially  calculated  to  develop 
them. 

Of  hydriatic  means  the  following  combination  is  especially  efficacious  in 
splanchnic  neurasthenia:  A  hot  foot  bath  with  the  cold  Winternitz  coil  to 
the  abdomen  and  cold  compresses  to  the  head  and  neck,  continued  for  twelve 
to  twenty  minutes,  is  the  first  part.  A  cold  sitz  of  four  to  six  minutes  dur- 
ation follows  and  the  treatment  is  concluded  by  a  wet  sheet  rub.  This  is 
especially  adapted  to  warm  weather.  During  the  winter  months  it  may  be 
necessary  to  apply  more  heat.  With  less  vigorous  patients,  the  first  combi- 
nation of  hot  foot  bath  with  cold  coil  to  the  abdomen  and  cold  compresses 
to  the  head  may  be  continued  thirty  minutes  or  longer  and  concluded  with  a 
cold  mitten  friction.  These  cold  applications  to  the  abdomen  and  pelvis 
produce  decided  and  prolonged  contraction  of  the  visceral  blood  vessels. 
The  fan  douche  to  the  hepatic  region  and  abdomen  also  accomplishes  much 
the  same  results. 

Hysteria 

While  some  cases  require  a  greater  proportion  of  sedative  treatment, 
nearly  all  require  more  or  less  of  tonic  treatment.  The  chief  result  to  be 
obtained  by  tonic  treatment  is  the  restoration  of  tone  to  the  neurons,  so  that, 
by  training,  self-control  becomes  possible.  The  methods  outlined  for 
neurasthenia  are  all  applicable  in  hysteria. 

Dyspepsia 

The  special  treatment  necessary  in  this  condition  will  be  considered  later, 
but  local  measures  unaccompained  by  general  tonic  treatment  are  often  insuf- 

7    The  Blues;  also  Spondylotherapy. 


166  STIMULANTS  AND  TONICS 

ficient  to  accomplish  fall  return  to  health.  The  measures  recommended  for 
anemia  and  those  necessary  in  neurasthenia  are  all  applicable  in  altered 
states  of  the  digestion. 

Insomnia 

t 

Treatment  of  this  condition  will  be  considered  under  "Sedative  Effects." 
A  large  number  of  cases  occurring  in  business  or  professional  men  may  be 
treated  almost  wholly  by  tonic  measures,  since  normal  fatigue  is  lacking 
because  of  insufficient  exercise.  Tonic  treatment  is  directed  toward  the 
production  of  moderate  fatigue,  so  that  sleep  may  be  induced  as  a  natural 
consequence.  The  tonic  measures  listed  above  are  nearly  all  applicable  in 
this  condition  and  should  be  accompanied  by  active  exercise  in  the  open  air. 


Chronic  Inebriety 

In  chronic  alcoholic  poisoning  the  tissues  are  in  a  state  of  lessened  activ- 
ity. Alcohol  circulating  in  the  system  for  months  or  years  tends  to  harden 
the  tissues,  causing  an  over-production  of  fibrous  connective  tissue  and  les- 
sening activity  of  parenchymatous  cells.  In  order  to  overcome  this  partial 
pickling  process,  it  is  necessary  to  use  the  most  extreme  measures,  such  as 
extreme  hot  and  cold,  to  wake  up  the  deadened  tissues,  especially  the 
brain  and  nervous  system.  Immediately  following  a  spree,  measures  should 
be  directed  toward  the  rapid  elimination  of  the  alcohol  imbibed.  If  the  pa- 
tient is  still  under  the  influence  of  the  liquor,  he  may  be  held  under  the  cold 
shower  to  stimulate  the  nerves  and  hasten  the  circulation.  After  the 
immediate  danger  is  past,  he  should  be  given  full  hot  tub  baths,  or  the  elec- 
tric light  bath,  accompanied  by  the  drinking  of  large  quantities  of  water. 
These  measures  hasten  the  elimination  of  the  alcohol.  Any  hot  treatment 
f-hould  be  followed  by  the  hot  and  cold  spray  or  shower.  The  hot  and  cold 
douche  is  an  excellent  means  of  stimulating  activity.  In  those  cases  that 
have  been  very  much  reduced  by  long  years  of  dissipation,  it  may  be  neces- 
sary to  employ  milder  measures,  such  as  the  neutral  bath,  the  wet  sheet 
pack,  fomentations,  and  the  cold  mitten  friction,  etc. 


Chronic  Articular  Rheumatism 

It  is  the  usual  custom  in  gouty  rheumatism  to  employ  extreme  sudorific 
measures.  Such  treatment,  unaccompanied  by  tonic  measures,  is  applicable 
only  in  obese  rheumatics,  and  in  those  cases  only  fora  limited  time.  While  any 
form  of  cold  treatment  may  temporarily  increase  the  stiffness  and  soreness, 
it  is  quite  essential  that  these  patients  should  be  given  tonic  treatment.  The 
cold  mitten  friction  is  probably  the  best  measure,  since  it  quickly  produces 
a  reaction  and  can  be  given  to  all  parts  of  the  body,  avoiding  the  joints. 
Tonic  measures  are  necessary,  not  only  to  increase  the  oxidation  and  elimin- 
ation of  toxins  and  the  surplus  of  nitrogenous  material  which,  by  long 
crowding  with  proteid  foods  of  high  purin  content  has  become  well  fixed; 
but  also  to  increase  the  building  up  process  and  the  general  body  weight. 


DIABETES  167 

The  nerve  tone  is  very  much  reduced  in  rheumatism  and  requires    special 
tonic  measures. 


Diabetes 

Diabetes  is  a  condition  in  which  the  system  is  unable  to  warehouse  and 
consume  the  carbohydrate  of  an  ordinary  diet.  The  disease  may  be  classified 
under  two  heads, —First,  an  alimentary  form  in  which  withdrawal  of  carbo- 
hydrate from  the  diet  for  a  time  produces  a  cure,  i.e.,  the  body  is  thereafter 
able  to  utilize  a  moderate  amount  of  sugar.  This  is  looked  upon  as  a  func- 
tional disease,  although  as  remarked  in  a  following  paragraph,  it  may 
be  due  to  partial  destruction  of  the  ductless  glands  of  the  pan- 
.creas.  Second,  a  permanent  or  organic  diabetes  in  which  excretion  of 
of  sugar  continues  after  the  withdrawal  of  all  carbohydrate.  It  has  been 
pretty  well  proven  that  destruction  of  the  islands  of  Langerhans  is  the 
causative  lesion  in  the  majority  of  cases.  These  ductless  bodies  are  believed 
to  secrete  a  glycolytic  or  oxidizing  ferment  (oxidase)  which  has  the  ability 
to  break  up  and  oxidize  the  sugar  molecules.  This  occurs  in  the  general 
system,  but  principally  in  the  muscles.  If  about  one-tenth  of  the  pancreas 
remains  intact  after  partial  extirpation,  diabetes  results  only  on  ingestion 
of  carbohydrate.  According  to  Thoinot  and  Delamere,  Langerhans  insuf- 
ficiency is  found  in  about  80  per  cent  of  cases.  Defect  in  the  glycogenic 
function  of  the  liver  may  also  cause  permanent  diabetes. 

The  usual  treatment  of  diabetes  is  directed  toward  securing  but  one  end, 
viz.,  decreasing  the  excretion  of  grape  sugar  by  lessening  the  ingestion  of 
carbohydrates;  substituting  protied,  chiefly  meat,  as  recommended  by 
Von  Noorden.  Chittenden 8  has  recently  shown  that  the  ingestion  of  pro- 
tied,  about  a  certain  minimal  requirement,  which  he  sets  at  about  35  to  60 
grams,  results  in  a  very  few  hours  in  the  excretion  of  practically  all  the 
nitrogen  in  the  form  of  urea,  the  residue  being  simple  carbohydrate  not  dis- 
tinguishable from  the  carbohydrate  taken  as  such.  Such  a  process  can 
hardly  be  said  to,  in  any  way,  conserve  the  body  powers.  The  great  amount 
of  useless  labor  demanded  of  the  liver  by  such  a  diet  must  result  in  over- 
working that  organ.  All  this  occurs,  to  say  nothing  of  the  detrimental 
effects  of  flooding  the  system  with  purins  from  the  large  quantities  of  meat 
which  the  Von  Noorden  diet  necessitates.  While  temporay  exclusion  of 
carbohydrate  from  the  diet  with  a  gradual  return  to  a  moderate  ingestion 
of  starches  and  sugars  is  quite  essential  and  an  excellent  plan  for  the  dietetic 
management  of  diabetes,  this  alone  does  not  meet  the  needs  of  the  condi- 
tion. The  real  cause  of  the  disease  lies  in  altered  carbohydrate  metabolism. 
The  sugar  passing  through  unoxidized  causes  a  loss  of  energy  that  should 
accrue  from  this  source.  In  other  words,  the  carbohydrate  fuel  falls 
through  the  grate  before  being  burned  because  of  lack  of  proper  regulation 
of  the  fire.  Lessening  the  amount  of  fuel  only  partially  remedies  the  effect. 

The  rational  management  must  therefore  aim  at  increasing  the  oxidation 
of  grape  sugar  and  thereby  preventing  its  elimination  in  an  unoxidized  state 
with  the  consequent  energy  loss.  There  are  no  known  medicinal  agents  or 

8.    Nutrition  of  Man,  p.  131. 


168  STIMULANTS  AND  TONICS 

even  any  mode  of  dietetic  management  which  will  accomplish  this  result. 
Experiment  has  revealed  the  fact  that  nothing  so  greatly  promotes  oxida- 
tive  changes  as  exercise  in  the  fresh  air  and  tonic  hydrotherapy.  The  effects 
of  these  agents  on  carbonaceous  metabolism  we  have  already  considered. 
Because  of  the  languor,  lessened  vitality,  and  great  susceptibility  to  fatigue 
which  is  an  almost  constant  accompaniment  of  diabetes,  it  is  often  difficult, 
not  to  say  unwise,  in  many  cases  to  pursuade  the  patient  to  exercise.  When 
there  is  much  loss  of  vitality  the  exercise  must  be  of  a  passive  nature,  i.  e., 
secured  by  massage.  Massage  stimulates  the  glycoly  tic  powers  of  the  mus- 
cles, improves  the  circulation  and  aids  nutritive  changes.  More  important 
than  this,  however,  are  the  effects  derived  from  applications  of  cold  water 
accompanied  by  friction  or  percussion.  Cold  frictions,  cold  douches  and 
mild  alternating  hot  and  cold  applications  effectually  stimulate  metabolism. 
Those  hydriatic  measures  which  are  accompanied  by  strong  mechanical 
stimuli  have  double  the  effect  of  cold  applications  without  friction  or  per- 
cussion. Cold  douches  have  been  shown  to  increase  oxidation  more  than  100 
per  cent.  These  means  also  improve  the  nutrition  of  the  skin,  and  so  aid  in 
preventing  many  of  the  annoying  cutaneous  complications. 

Because  of  the  lowered  vitality  of  almost  all  diabetics,  the  treatment 
must  be  carefully  graduated  and  mild  tonics  used  at  first.  Local  hot  appli- 
cations followed  by  the  wet  hand  rub  or  cold  mitten  friction  may  be  used  to 
begin  with,  also  the  neutral  faradic  tub,  graduated  shower  and  cool  affu- 
sions. After  becoming  accustomed  to  these  treatments  the  patient  may, 
if  in  good  flesh,  be  given  a  wet  sheet  rub,  dripping  sheet  rub,  cold  shallow 
bath  and  alternate  douches.  In  some  cases  the  cold  plunge  may  even  be 
ventured  upon.  As  rapidly  as  able,  the  patient  should  be  encouraged  to 
take  moderate  exercise  in  the  open  air;  the  effect  is  greater  if  the  air  is 
cold.  These  measures  improve  the  appetite  and  stimulate  digestion  and 
assimilation.  The  feeling  of  languor  and  debility  gives  way  to  a  greater 
inclination  to  exercise,  and  so  hydrotherapy  indirectly  makes  possible  the 
use  of  the  other  great  aid  in  oxidation — bodily  activity. 

With  thin  diabetics,  the  prognosis  is  less  favorable.  They  can  take  only 
the  milder  tonic  treatments.  Neither  do  they  bear  well  any  great  reduc- 
tion in  the  diet.  But  even  with  such  unfavorable  conditions,  astonishingly 
good  results  may  be  obtained  by  carefully  graded  hydrotherapy  combined 
with  light  massage.  Much  time  should  be  spent  in  the  open  air  and  sun- 
shine, careful  attention  being  paid  to  general  hygiene  and  especially  to  good 
skin  activity. 


Cerebral  Congestion 

Due  to  the  Effects  of  Sunstroke  or  Heat  Stroke 

Patients  who  have  once  suffered  from  sunstroke  must  select  a  cold  climate 
in  which  to  live.  Even  moderate  heat  for  any  length  of  time  produces 
harmful  results.  It  would  seem  that  in  this  condition  the  vasomotor  cen- 
ters have  been  so  interfered  with  that  there  is  a  loss  of  vascular  control. 
This  may,  in  some  cases,  be  so  extreme  that  even  a  short  hot  treatment 
limited  to  a  small  area  may  induce  general  vaso-dilatation  with  a  special 


VALVULAR  HEART  DISEASE  169 

tendency  toward  cerebral  congestion.  The  condition  is  best  treated  by  cold 
applications  accompanied  by  friction.  No  hot  applications  at  all  should  be 
used.  During  all  treatment,  the  head  should  be  kept  cool  by  cold  compresses 
and  the  ice  bag,  or  the  ice  cravat  to  the  neck.  The  cold  mitten  friction,  cold 
towel  rub,  wet  sheet  rub,  cool  or  cold  showers  and  sprays  may  all  be  used 
according  as  the  conditions  indicate.  If  the  brain  seems  unduly  congested 
a  great  deal  of  time,  derivation  is  best  secured  by  the  cold  percussion 
douche  to  the  feet. 


Valvular  Heart  Disease 

Etiology  and  Pathology 

Organic  heart  disease  refers  to  such  diseases  of  the  heart  as  are  due  to 
gross  structural  changes.  The  term  is  applied  almost  exclusively  to  chronic 
valvular  disease.  The  larger  number  of  cases  are  the  result  of  some  acute 
inflammatory  condition  on  or  about  the  valves.  These  valve  inflammations 
may  arise  as  complications  of  rheumatic  fever,  tonsillitis,  scarlet  fever,  sep- 
sis, gonorrhoea,  pneumonia,  pleurisy,  or  pulmonary  tuberculosis.  Predis- 
positions are  found  in  prolonged  and  heavy  muscular  exercise,  autointoxica- 
tion, gout,  alcoholism,  syphilis,  Bright's  disease  and  arteriosclerosis.  The 
result  is  a  valve  orifice  either  too  large  or  too  small.  Scar  tissue  following 
the  inflammation  may  cause  the  valve  segments  to  adhere  to  each  other  and 
so,  by  partially  obstructing  the  orifice,  cause  stenosis;  the  valve  leaflets 
may  be  partially  destroyed  or  their  attachments  weakened  so  that  the  ori- 
fice is  too  large,  or  the  heart  dilated  so  that  the  segments  are  incompetent 
to  close  the  opening. 

In  the  first  case,  that  is,  stenosis,  too  little  blood  passes  through  the  ori- 
fice and  extra  force  is  required  to  overcome  the  obstruction.  In  the  latter 
case,  part  of  the  blood  returns  through  the  enlarged  opening  or  past  the 
incompetent  valves  so  that  regargitation  takes  place  at  every  heart  beat. 
Because  of  the  former  condition,  the  first  change  in  the  heart  muscle  is  that 
of  hypertrophy.  In  the  second  condition,  the  first  change  is  that  of  dilata- 
tion of  one  or  more  cardiac  chambers.  If  compensated,  both  conditions 
result  in  great  hypertrophy  and  thickening  of  the  muscular  wall.  The  maxi- 
mum force  of  the  heart  will  be  greater  than  normal,  but  the  work  required 
of  it  is  also  greater,  so  that  in  this  conditioj,  its  reserve  force  above  what 
it  ordinarily  uses  is  less  than  the  normal  reserve.  Here  the  heart  is  said  to 
to  be  in  a  state  of  compensation,  since  the  muscle  is  so  much  hypertrophied 
as  to  still  be  able  to  perform  its  work  under  ordinary  circumstances.  Some- 
times there  is  little  or  no  such  reserve,  i.  e.,  the  heart  may  have  barely 
enough  force  for  its  work  when  the  body  is  at  rest.  In  this  condition,  the 
heart  is  said  to  be  in  a  state  of  broken  compensation.  This  state,  that  is, 
where  the  maximum  force  is  in  constant  use,  is  revealed  by  such  symptoms 
as  edema,  cyanosis,  dyspnoea,  heart  pang  or  distress,  rapid  pulse,  palpitation, 
sleep  start,  enlarged  liver,  etc. 

Moderate  muscular  work  demands  four  times  the  energy  used  at  rest,  and 
the  total  reserve  power  of  the  heart  muscle  is  from  eleven  to  thirteen  times 


170 


STIMULANTS  AND    TONICS 


the  normal  output  during  rest.  9  This  proportion  is  shown  in  Fig.  29,  I. 
In  the  case  of  a  valvular  lesion  so  bad  as  to  require  three  or  four  times 
the  usual  expenditure  of  energy,  it  will  be  seen  that  only  during  complete 
physical  rest  will  the  heart  be  able  to  accomplish  its  work  (Fig.  29,  II). 
Moderate  muscular  exercise  will  demand  more  energy  than  it  possesses  and 
so  will  be  accompained  by  signs  of  broken  compension.  In  order  that  com- 


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Fig.  29.    Diagram  showing  dynamic  conditions  in  valvular 
heart  disease. 

a.  Force  required  at  rest  under  conditions  indicated. 

b.  Additional  force  demanded  by  moderate  muscular  work. 

c.  Reserve  cardiac  force  above  that  needed  for  moderate 
work. 

pensation  may  be  restored,  the  muscular  wall  must  nearly  double  its  thick- 
ness to  possess  even  a  little  reserve  force  as  shown  in  Fig.  29,  III. 

Treatment 

It  will  be  readily  seen  that  the  above  conditions  set  forth  two  indications 
for  treatment.  First,  so  shaping  conditions  that  the  heart  may  be  given 
opportunity  to  increase  its  muscular  tissue  and  thereby  its  reserve  force. 
Second,  as  much  as  possible,  relieve  the  heart  of  part  of  its  work,  not  only 

9     Hutchison— Applied  Physiology,  p.  116. 


VALVULAR  HEART  DISEASE  171 

temporarily  in  order  to  bring  about  the  condition  just  mentioned,  but  also  to 
constantly  assist  the  overtaxed  organ.  These  indications  are  met  in  the 
following  procedures: — 

1.  Rest,  Physical  and  Mental.    This  is  first  and  foremost  in  importance. 
It  is  necessary  that  absolute  physical  rest  be  observed  in  the  state  of  broken 
compensation.    Exercise  should  not  be  permitted  until  the  heart  has  acquired 
at  least  some  reserve  force.     According  to  the  gravity  of  the  case,  physical 
res\  may  be  secured  by  absolute  quiet  in  bed,  by   rest   in   a  wheel   chair 
with  an  attendant,  or  by  restricted  exercise.     While  at  rest,  the  body  tis- 

.sues  demand  less  oxygen  and  consequently  less  rapid  circulation.  It  is 
quite  as  essential  to  eliminate  all  nerve  strain,  such  as  worry,  apprehension, 
business  or  social  cares,  etc.  Through  the  avenue  of  the  sympathetic  system, 
these  irritate  and  overstimulate  the  intrinsic  nerves  of  the  heart  muscle. 

2.  The  Ice  Bag  to  the  Heart.     This  is  one  of  the  most  efficient  means  we  pos- 
sess in  its  ability  to  produce  direct  tonic  effects  upon  the  heart  muscle.     Pro- 
longed, continued  cold  lessens  the  rate  and  increases  the  length  of  the  period 
of  rest  (diastole) .     It  also  shortens  the  systole  and  increases  its  force.     The 
ice  bag  should  be  well  wrapped  to  modify  the  intensity  so  that  the  applica- 
tion may  be  prolonged.     In  some  cases,  the  cold  compress  is  to  be  preferred. 
While  the  ice  bag  tends  to  increase  the  force  of  the  systole,  it  can  hardly 
be  said  to  come  under  the  head  of  pure  stimulants,  since  by  its  repeated  use, 
the  effects  of  overstimulation  are  never  seen.     It  always  exercises  a  bene- 
ficial effect  in  aiding  hypertrophy  of  the  heart  muscle,  since  by  its  shorten- 
ing the  systole  and  increasing  the  length  of  the  diastole,  the  actual  period 
of  rest  is  increased.     It  may,  therefore,  be  said  to  be  a  true  physiologic  meas- 
ure. 

3.  Measures  which  Stimulate  the  Peripheral  Heart,  performing  part  of 
the  work  of  circulation,  increasing  its  activity  and  so  aiding  the  central  heart 
In  the  chapter  on  the  Peripheral  Heart,  we  have  discussed  at  length  the 
physiology  of  the  blood-vessels,  there  normal  action  and  the  rationale  of  the 
measures  used  to  increase  there  action. 

We  need  here  only  briefly  summarize  the  facts  already  pointed  out.  In- 
dependently of  the  heart,  the  blood  vessels  exert  a  pumping  or  propulsive 
action  upon  the  blood  stream. 

Lauder  Brunton 10  makes  the  following  observation  relative  to  this  activity: 
"When  working  under  Professor  Ludwig  in  1869,  he  directed  my  attention 
to  the  contractile  power  of  the  small  arteries  apart  from  any  nerve  center, 
and  while  watching  their  movements  I  have  sometimes  seen  a  regular  pen- 
staltic  action  take  place,  by  which  the  blood  was  driven  forward  in  the 
arteriole  just  as  faBcal  matter  would  be  driven  forward  in  the  intestine." 

"Franke  discusses  the  various  theories  prevailing  in  regard  to  the  functional 
importance  of  the  peripheral  blood  vessels.  His  conclusions  reaffirm,  he 
asserts,  that  the  peripheral  vessels  have  an  independent  pressure  and  suc- 
tion action  similar  to  that  of  the  heart;  this  assumption  is  sustained  by  their 
anatomic  structure,  physiologic  experiments,  direct  observation  of  the  blood 
vessels  in  living  animals  and  in  certain  pathologic  conditions  in  man.  At 

10    Therapeutics  of  the  Circulation,  p.  5. 


172  STIMULANTS  AND  TONICS 

the  points  where  there  is  the  greatest  resistance  to  the  circulation  Nature 
has  placed  a  system  of  especially  powerful  blood  vessels  like  a  second  peri- 
pheral heart,  as  in  the  portal  and  intestinal  vessels.  Compensation  may  fail 
from  disturbances  in  the  peripheral  vessels  as  well  as  in  the  heart  itself,  and 
the  peripheral  system  may  compensate  the  heart  at  need;  the  vessels  in  the 
abdomen  especially  are  the  last  resort  of  all  means  to  maintain  the  balance 
of  the  circulation.  These  views,  he  considers,  explain  the  beneficial  effects 
of  gymnastics,  massage  and  baths."11  • 

In  disease,  as  long  as  there  remains  any  vasomotor  control  at  all,  the  activ- 
ity of  the  blood  vessels  may  be  stimulated  by  applications  to  the  skin  surface.  _ 
The  condition  of  the  blood  vessels  to  be  sought  in  the  treatment  of  valvular 
heart  disease  is  that  known  as  active  dilatation,  not  only  of  the  arterioles, 
but  also  of  the  other  blood  vessels.  It  consists  of  an  alternate  contraction 
and  relaxation  occurring  at  regular  intervals.  It  is,  in  short,  a  pumping 
action.  It  is  often  astonishing  to  note  the  amount  of  assistance  rendered  the 
circulation  in  this  way,  as  shown  by  prompt  decrease  in  the  pulse  rate  fol- 
lowing or  even  during  some  of  the  procedures  listed  below.  These  may  be 
given  separately,  combined  in  one  treatment  or  at  different  times  during  a 
course  of  treatment,  as  indicated  by  conditions  in  the  individual  case. 

(a)  Massage.     Friction  is  perhaps  the  mildest  of  measures  by  which  the 
peripheral  circulation  may  be  stimulated.     It  stimulates  the  arterioles  and, 
by  proper  movements,  the  venous  circulation  is  hastened.     All  the  other  pro- 
cedures of  massage  are  also  vasomotor  excitants. 

The  procedure  of  deep  kneading  accomplishes  more  than  the  other  move- 
ments of  massage.  It  acts  upon  the  circulation  in  almost  the  same  manner 
as  exercise.  The  alternate  compression  and  release  of  the  muscles  forces 
on  their  contained  blo^/d  so  that  the  rate  of  flow  is  greatly  accelerated. 
Lander  Brunton  12  records  graphically  the  results  of  some  interesting  experi- 
ments showing  the  increase  in  the  rate  of  venous  outflow  from  muscles  dur- 
ing and  after  massage.  In  some  instances  the  rapidity  was  increased  two 
or  three  times  the  normal  rate. 

Mechanical  vibration  is  quite  similar  in  its  effect  to  manual  massage. 
Vibration,  when  properly  given,  is  an  excellent  means  of  assisting  the  peri- 
pheral circulation,  especially  that  of  the  feet  and  limbs.  Vibration  may  also 
be  given  to  the  back  and  other  parts,  as  indicated. 

(b)  Hydriatic  Vasomotor  Tonics.     The  cold  mitten  friction  has  the  great- 
est range  of  adaptability  in  organic  heart  disease.     It  can  be  used  in  all 
stages  from  the  inception  of  the  acute  endocarditis  through  all  the  varying 
conditions  of  established  or  broken    compensation.     This  is  largely  due  to 
the  readiness  with  which  it  may  be  made  a  mild,  medium  or  powerful  vaso- 
motor tonic  and  stimulant.     This  can  be  accomplished  by  varying  the  tem- 
perature of  the  water  used  and  altering  the  amount  and  vigorousness  of  the 
friction  given.     We  have  never  observed,  even  after  the  most  vigorous  cold 
mitten  friction,  or  its  long  use  over  a  period  of  months,  any  overstimulation 
such  as  does  sometimes  occur  with  the  effervescent  bath.     The  cold  mitten 

11  Abstract  in  Journal  of  American  Medical  Association  of  article  by  M.  Franke  in   Wiener 
klinische  Wochenschrift,  March  10,  1910  XXIII,  No.  10,  p.  347. 

12  Therapeutics  of  the  Circulation,  p.  135. 


VALVULAR  HEART  DISEASE  17S 

friction  and  ice  bag  can  be  used  in  the  acute  stage  of  endocardia!  inflamma- 
tion, while  it  might  be  dangerous  to  use  the  Nauheim  bath  in  this  stage. 
There  are  many  other  hydriatic  measures  similar  in  affect  to  the  cold  mitten 
friction.  Each  has  its  advantages  and  special  indications,  as  well  as  limita- 
tions. The  following  is  a  list  of  the  more  important  and  commonly  used 
hydriatic  measures  in  the  treatment  of  organic  heart  disease:  The  salt 
glow;  hot  and  cold  to  the  spine;  hot  and  cold  douche  to  the  spine,  legs  and 
feet;  the  alternate  hot  and  cold  foot  or  leg  bath.  Short  hot  fomentations 
followed  by  a  brisk  but  brief  cold  mitten  friction  may  be  given  to  any  part 
of  the  body  as  a  means  of  stimulating  the  peripheral  circulation. 

(c)  Nauheim   or   Effervescent  Bath.     The  essential  feature  here  is  the . 
chemical  irritation  of  the  skin  produced  by  the  carbon  dioxide  and  salines 
with  which   the    water   is    charged.     Natural   carbonated    waters    can    be 
secured  in  only  a  few  localities,  but  the  carbonic  acid  gas  may  be  produced 
artificially  in  any  one  of  several  ways.     It  powerfully  stimulates  the  vaso- 
motors,  having,  however,  a  cumulative  action  on  the  vaso-dilators  l3  so  that 
the  heart  is  left  without  a  resistance  governor.     For  this  reason  it  is  neces- 
sary to  discontinue  the  treatment  at  intervals  in  order  to  obviate  palpitation 
and  other   disturbing    symptoms.     The    cutaneous   irritation    also    reflexly 
stimulates  the  heart  (Here).      This  may  be  another  factor  in  the  produc- 
tion of  palpitation  by  over-stimulation.     The  cooler  the  water  the  less  likely 
its  occurrence. 

When  the  patient  first  begins  to  take  the  Nauheim  bath,  it  should  not  be 
continued  longer  than  about  eight  minutes  at  a  temperature  of  95°  F.  Five 
minutes  may  be  better  in  some  cases.  An  ice  bag  or  cold  coil  should  be 
placed  over  the  heart.  The  bath  may  be  repeated  two  or  three  times  a  week 
for  from  two  to  four  weeks.  It  is  usually  best  to  give  a  course  of  about  twelve 
treatments,  when  two  or  three  weeks  should  be  omitted.  In  each  succeeding 
treatment,  the  temperature  of  the  water  may  be  slightly  lowered  until  the 
bath  is  taken  in  water  even  as  low  as  80°.  The  duration  of  the  bath  may  he 
increased  up  to  twelve,  or  under  exceptional  circumstances,  fifteen  minutes. 
The  longer  the  duration  of  each  bath  and  the  more  frequent  its  repitition,  the 
greater  is  the  liability  to  over-stimulation.  This  is  evidenced  by  palpitation, 
tachycardia,  cyanosis  and  dyspnoea. 

(d)  Resistant  Gymnastics.     This  system  is  known  as  the  Schott  treat- 
ment.    As  carried  out  by  the  Schott  Brothers,  it  is  combined  with  the  Nau- 
heim bath.     It  consists  of  a  series  or  system  of   graduated   exercises.     At 
first  the  patient  is  assisted  by  an  attendant;  later,  with  apparatus  or  alone. 
First  one  group  of  muscles  is  exercised  and  then  another  until  the  principal 
muscle  groups  of  the  body  have  been  gone  over.     For  example,  while  the 
attendant  resists,  the  patient  gradually  contracts    the    biceps,    flexing    the 
forearm.     When  the    forearm  has    been  flexed,    the  patient    contracts    the 
extensors  while  the  attendant  resists  the  movement.     This  is  gone  through 
with  a  number  of  times  for  each  group  of  muscles.     With  each  succeeding 
treatment  the  number  of  movements  and  the  strength  of  the  resistance  is 
increased.     The  gradual  contraction  and  relaxation  of   first    one    and    then 
another  group  of  muscles  hastens  the  peripheral  circulation  and    tends    to 
induce  the  state  of  active  dilatation  of  the  blood-vessels.     This  treatment 

13    Hare — Practical  Therapeutics. 


174  STIMULANTS  AND  TONICS 

should  not  be  applied  in  acute  endocarditis,  but  is  applicable  in  the  chronic 
stage  where  compensation  is  not  seriously  broken. 

(e)  Oertel  Method.  General  exercises,  such  as  walking,  use  of  the  arms, 
etc.,  follow  as  a  natural  consequence  of  the  method  just  described.  As  a 
system,  the  Oertel  method  consists  in  graduated  climbing  exercises,  up  hills 
of  various  grades  and  finally  even  mountain  climbing.  At  first,  the  patient 
walks  for  short  distances  each  day;  and  later,  longer  distances  and  up  steeper 
grades.  This  is,  of  course,  applicable  only  where  a  fair  degree  of  compen- 
sation has  already  been  established;  never,  when  the  compensation  is  broken 
or  in  the  slightest  impaired.  Where  systematically  followed  for  months  or 
years,  it  has  resulted  in  much  good  and  will  secure  for  the  patient  the  maxi- 
mum cardiac  reserve. 

These  measures  combined  with  careful  diet  regulation,  fresh  air  and  sun- 
shine will  give  results  which  often  appear  like  a  complete  cure,  but  of  course, 
do  not  remove  the  defect  in  the  heart.  Even  in  the  beginning  of  the  incompe- 
tency,  the  progress  may  be  stayed  for  years.  The  promptness  with  which  these 
measures  act  and  their  efficiency  has  to  be  seen  to  obtain  a  real  appreciation 
of  their  value.  For  example,  the  ice  bag  to  the  heart,  accompanied  by  a 
cold  mitten  friction,  may  reduce  the  pulse  from  115  or  120  per  minute  to  100 
or  less  within  fifteen  or  twenty  minutes.  In  cast  of  a  dilated  heart,  the 
cardiac  dullness  may  decrease  more  than  an  inch  in  diameter  and  the  apex 
retract  half  an  inch  or  more  toward  its  normal  position  following  a  single 
treatment.  In  case  the  valve  is  relatively  insufficient,  the  murmur  occa- 
sioned by  this  insufficiency  may  entirely  disappear,  whereas  before  treat- 
ment, it  may  have  been  considered  to  constitute  a  real  organic  lesion.  The 
minor  murmurs  of  valves  secondarily  affected  often  disappear  following  a 
treatment  of  fifteen  minutes  with  the  ice  bag  to  the  heart  and  the  cold  mit- 
ten friction,  or  ten  minutes  in  a  Nauheim  bath. 

Counterindications.  Extreme  stimulants  and  excitants  are  counterindi- 
cated  in  organic  heart  disease,  unless  it  may  be  in  emergency.  For  this 
reason,  the  percussion  douche  to  the  chest,  wet  sheet  rub,  the  cold  plunge 
and  such  measures  should  not  be  used.  The  use  of  electricity  in  any  form 
may  produce  shock.  The  electric  light  bath  is  usually  counterindicated  or, 
if  used  at  all,  it  must  be  in  those  patients  which  have  acquired  a  good  degree 
of  compensation  and  then  only  for  a  short  time.  All  other  extreme  sudo- 
rific measures  are  counterindicated. 

General   Program 

We  have  already  outlined  under  the  head  of  "Endocarditis,"  the  treat- 
ment for  the  stage  of  acute  inflammation.  As  soon  as  the  endocardial  in- 
flammation subsides,  the  patient  may  be  given  daily  or  three  times  a  week 
a  light  general  massage,  avoiding  the  chest.  The  ice  bag  should  be  applied 
to  the  heart  four  or  five  different  times  during  the  day,  being  kept  in  place 
from  fifteen  to  forty-five  minutes  each  time.  Once  daily,  the  patient  should 
have  a  treatment  consisting  of  a  combination  of  some  of  the  following  meas- 
ures: Hot  foot  bath,  fomentations  to  the  abdomen,  hot  and  cold  to  the  spine, 
I'uld  mitten  friction  and  cold  towel  rub.  This  tonic  treatment  is  best  given 
during  the  forenoon.  The  massage  may  be  reserved  for  the  afternoon  or 


VALVULAR  HEART  DISEASE  175 

evening.  If  there  is  much  restlessness  or  insomnia,  it  may  be  best  to  give 
a  hot  and  cold  foot  bath  just  before  retiring.  During  this  time,  the  patient 
should  be  kept  in  bed;  but  when  the  pulse  has  become  normal,  he  may  change 
to  the  wheel  chair,  and  later,  be  allowed  about  the  room,  walking  a  few  steps 
or  for  short  distances  only.  The  pulse  should  become  normal  before  any 
regular  walking  exercises  are  taken.  The  patient  may  now  be  given  a  salt 
glow,  alternate  douche  to  the  feet  and  legs,  graduated  shower,  etc.  The 
Nauheim  bath  may  be  given  after  the  temperature  has  been  normal  for  a 
month  or  two.  This  should  be  followed  by  the  Schott  treatment  which,  at 
first,  should  last  only  a  few  minutes  and  consist  of  mild  exercises.  Later, 
this  may  be  prolonged  and  increased  in  severity. 

In  case  the  patient  comes  under  observation  during  the  chronic  stage, 
with  compensation  broken,  the  treatment  may  be  begun  at  this  point  or  per- 
haps with  milder  measures.  The  resistant  movements  should  not,  however, 
be  used  during  the  stage  of  broken  compensation.  Care  must  be  taken  that 
the  patient  is  not  treated  too  frequently.  This  may  often  seem  necessary, 
but  it  will  be  found  better  to  allow  the  patient  sufficient  time  for  rest. 
Three  treatments  a  day  are  usually  ample  and  only  one  of  these  should  con- 
sist of  the  more  vigorous  stimulating  measures.  The  evening  treatment 
should  be  mild  in  character,  sedative  and  conducive  to  sleep.  The  after- 
noon treatment  may  be  the  hot  and  cold  foot  bath  followed  by  massage. 
This  at  first  should  be  mild  and  not  last  more  than  fifteen  or  twenty  minutes. 

Complications 

Edema.  The  edema  of  the  feet  and  legs  accompanying  cardiac  disease 
will  improve  as  compensation  is  restored,  so  that  all  of  the  measures  recom- 
mended during  the  stage  of  broken  compensation  will  aid  in  the  reducing  of 
the  dropsy.  The  measure  which  we  have  found  most  useful  is  the  alternate 
hot  and  cold  leg  bath.  The  water  should  come  sufficiently  high  to  more 
than  cover  the  edematous  part.  The  limbs  should  be  immersed  in  hot 
water  for  one  and  a  half  to  two  minutes  and  then  in  the  cold  for  ten  to 
fifteen  seconds.  It  is  best  to  make  the  hot  water  as  hot  as  can  be  borne, 
gradually  adding  more  hot  water  as  the  toleration  increases.  The  cold 
water  may,  at  first,  be  used  at  a  temperature  of  50°  to  70°  F.  Later, 
chunks  of  ice  should  be  put  into  the  receptacle  for  the  cold  water.  From 
five  to  ten  changes  may  be  made  at  one  treatment.  The  limbs  should  be 
dried  from  the  cold  water  and  the  drying  followed  by  massage  consisting 
principally  of  centripetal  movements.  The  limbs  should  be  kept  elevated 
until  the  edema  has  nearly  all  subsided. 

In  the  minor  grades  of  edema,  that  is,  where  there  is  swelling  only  about 
the  ankles,  vibration  may  be  applied  to  the  feet  by  means  of  the  vibrating 
foot  machine.  The  hot  and  cold  leg  bath  together  with  massage  should 
be  repeated  daily. 

Congestion  of  Liver.  The  liver  may  remain  congested  for  some  time  after 
the  heart  condition  has  materially  improved.  Because  of  the  nature  of  the 
hepatic  tissue,  the  organ  tends  to  remain  enlarged.  The  passive  congestion 
does  not  readily  respond  to  treatment.  In  spite  of  these  facts,  an  enorm- 
ously enlarged  liver  may  be  caused  to  return  to  nearly  normal  size  by  a 


176  STIMULANTS  AND  TONICS 

month  or  two  of  vigorous  treatment.  The  patient  should  be  given  large 
hot  fomentations  over  the  liver.  It  will  be  found  helpful  to  place  an  ice  bag 
under  the  center  of  the  fomentation.  The  ice,  having  a  greater  reflex 
effect,  tends  to  contract  the  blood  vessels  of  the  liver,  while  the  hot  appli- 
cation shows  its  effect  chiefly  in  derivation.  Alternating  with  this  treatment, 
the  revulsive  compress  or  hot  and  cold  to  the  liver  should  be  used.  The  alter- 
nate douche  to  the  hepatic  region  is  one  of  the  best  measures  that  can  be 
used.  While  acting  somewhat  indirectly  by  a  derivative  process,  the  hot 
and  cold  leg  bath  will  be  found  to  be  as  efficient  as  the  local  treatment. 

Acute  Edema  of  the  Lungs.  This  condition  may  come  on  because  of  chill- 
ing or  nervous  shock.  The  heart  becomes  engorged  and  the  chambers 
dilated  at  the  same  time.  The  patient  should  be  immediately  wrapped  in 
a  large  blanket,  the  feet  and  legs  being  placed  in  hot  water  and  an  ice  bag 
held  against  the  precordia.  It  is  usually  necessary  for  the  patient  to  sit  up. 
The  ice  bag  may  be  removed  every  three  or  four  minutes,  the  skin  being 
warmed  by  brisk  rubbing.  Another  attendant  should  apply  to  the  spine  a 
large  fomentation  so  as  to  cover  its  entire  length  and  breadth.  As  soon  as 
the  skin  is  well  reddened,  a  brief  but  very  cold,  brisk  cold  mitten  friction 
should  follow.  Another  fomentation  may  be  applied  to  the  spine,  or  the 
part  may  be  dried  well  and  covered  with  the  blanket.  Each  arm  and  leg 
should  be  treated  in  a  similar  manner,  that  is,  the  skin  well  warmed  and 
reddened  by  a  fomentation  and  immediately  followed  by  the  cold  mitten 
friction.  Each  part  should  be  thoroughly  dried  with  a  rough  towel  and  the 
drying  followed  by  friction  with  the  bare  hand  until  the  part  is  again  warm 
and  red.  The  object  to  be  obtained  in  this  treatment  is  the  drawing  of  the 
blood  from  the  heart  and  lungs  to  the  skin  and  skeletal  muscles.  This  can 
not,  however,  be  effectually  done  by  hot  alone,  but  must  be  accomplished 
by  what  may  be  termed  "collateral  fluxion,"  that  is,  the  blood  vessels  of 
the  surface  must  be  stimulated  to  unusual  activity  so  that  the  blood  will  be 
held  in  the  periphery.  This  not  only  acts  powerfully,  but  leaves  no  bad 
after  effects  such  as  are  frequently  noticed  when  these  complications  are 
treated  by  digitalis,  nitroglycerin  and  strychnin.  Neither  are  these  stimu- 
lants able  to  accomplish  the  desired  result  in  extreme  cases.  In  a  few  hours, 
the  moist  rales  in  the  chest,  which  can  at  first  be  heard  at  some  distance, 
will  have  entirely  disappeared.  The  finer  crepitant  rales  which  remain  in 
the  bases  of  the  lower  lobes  should  clear  up  in  one  to  three  days. 

Palpitation  and  Arrhythmia.  These  conditions  are  largely,  if  not  wholly,  - 
due  to  digestive  disturbances,  especially  that  form  of  indigestion  accom- 
panied by  gas  formation.  Treatment  should  therefore  be  directed  toward 
the  relieving  of  constipation  and  decreasing  of  amylaceous  dyspepsia.  It 
may  be  necessary  to  avoid  even  moderate  quantities  of  starchy  foods  unless 
most  thoroughly  dextrinized.  Tachycardia  is  best  controlled  by  the  ice  bag, 
cold  mitten  friction,  rest,  etc. 


Obesity  with  Fatty  Heart 

It  is  not  safe  to  employ  extreme  sweating  measures  in  obesity  accom- 
panied by  fatty  degeneration  of  the  heart  muscle.  Consequently,  the  treat- 
ment of  these  cases  at  the  hot  springs  is  a  dangerous  procedure.  The  case 


PURE  STIMULANTS  177 

must  be  treated  in  much  the  same  manner  as  one  of  organic  heart  disease. 
The  patient  should  be  kept  at  rest  with  an  ice  bag  over  the  heart  for  a  con- 
siderable portion  of  the  time.  Beside  this,  the  patient  should  be  given  cold 
mitten  frictions,  cold  towel  rubs,  hot  and  cold  to  the  spine,  general  massage 
and  later,  the  alternate  douche  to  the  spine  and  legs,  hot  and  cold  footbath, 
wet  sheet  rub,  etc.  Treatment  should  be  very  carefully  graduated  so  that 
the  heart  is  not  subjected  to  overstimulation  before  it  has  sufficiently  increased 
its  strength. 

Excitant,  Stimulating  and  Extreme  Tonic  Effects 

In  many  emergencies,  it  is  necessary  to  employ  extreme  stimulating  meas- 
ures. These  aim  at  the  sustaining  of  vital  activity  in  order  to  tide  the  sys- 
tem over  a  crisis  or  until  such  time  as  the  natural  vitality  of  the  patient 
comes  to  his  assistance.  Such  measures  are  especially  directed  toward  the 
heart,  blood  vessels  and  respiration.  In  collapse,  surgical  shock,  drowning 
and  asphyxia,  these  measures  are  indicated.  As  we  have  noted  many  times, 
the  greatest  amount  of  assistance  to  the  heart  can  be  given  by  vigorous 
stimulation  of  the  peripheral  blood  vessels.  In  addition  to  such  measures, 
certain  applications  may  be  used  which  have  a  direct  reflex  effect  upon  the 
heart  itself.  The  most  efficient  reflex  stimulation  comes  through  the  accel- 
erator nerves.  Short,  very  hot  fomentations  may  be  applied  to  the  front 
of  the  chest,  well  covering  the  heart  area.  This  should  Ije  continued  from 
thirty  seconds  to  a  minute  and  immediately  followed  by  the  rubbing  of  a 
cake  of  ice  over  the  heart.  The  extreme  change  in  temperature  produces 
powerful  stimulation.  The  part  should  be  immediately  dried,  after  which 
a  second  fomentation,  very  hot  and  continued  for  half  a  minute  or  more 
may  be  used,  again  followed  by  the  ice  rub.  After  three  or  four  such  appli- 
cations, it  is  well  to  rub  vigorously  with  the  bare  hand  the  skin  of  the  pre- 
cordia.  These  procedures  may  be  given  at  the  same  time  as  artificial  res- 
piration. 

A  very  efficient  stimulating  measure  is  the  slapping  of  the  chest  with  a 
cold  wet  towel.  If  this  is  done  during  the  movements  of  artificial  respira- 
tion, it  should  be  given  while  the  inspiratory  movement  is  made.  In  the 
asphyxia  of  the  new-born  infant,  thermic  applications  are  indispensable.  If 
slapping  of  the  chest  and  buttocks  does  not  produce  respiration,  it  is  well 
to  employ  the  alternate  hot  and  cold  immersion.  Two  large  dishpans  will 
be  found  handy  containers  for  the  hot  water  and  cold  water.  The  hot  water 
must  not  be  hot  enough  to  produce  a  burn  or  even  erythema.  It  must  be  of 
such  a  temperature  as  may  be  well  borne  on  the  back  of  the  hand  or  the 
cheek.  The  cold  water  should  produce  decided  excitation,  but  ice  water 
should  not  be  used.  The  child  should  be  held  in  the  hot  water  for  five  or 
even  ten  seconds  and  then  merely  dipped  in  the  cold  water.  It  should  then 
be  returned  to  the  hot  for  about  the  same  length  of  time  and  again  dipped 
in  the  cold.  This  procedure  is  usually  the  most  effectual  stimulating  meas- 
ure that  can  be  used.  All  other  means  of  resuscitating  the  new-born  have 
their  place  and  applicability.  The  physician  should  not  too  readily  become 
discouraged  in  working  with  an  asphyxiated  infant.  It  may  require  half  or 
three  quarters  of  an  hour  to  so  stimulate  the  heart  and  respiration  that  the 
child  will  continue  to  breath  without  artificial  means. 


178  STIMULANTS  AND  TONICS 

Uterine  Stimulants 

Uterine  excitation  may  be  necessary  in  order  to  produce  two  different 
classes  of  effects,  viz.,  contraction  of  the  uterine  muscle  and  production  or 
increase  of  menstrual  flow. 

Oxytocic  Effects.  In  cases  of  inertia  uteri,  much  may  be  accomplished  with- 
out the  use  of  forceps.  That  which  has  given  us  the  best  results,  produc- 
ing the  most  powerful  contractions,  has  been  the  use  of  the  ice  bag  or  cold 
compress  to  the  lower  abdomen,  applied  intermittently,  especially  just  at 
the  beginning  of  the  pain,  or  short  intermittent  applications  of  cold  to  the 
breasts.  Alternate  hot  and  cold  applications  may  also  be  made  to  the  lower 
abdomen.  Both  areas  are  in  direct  reflex  connection  with  the  uterus  and 
produce  powerful  uterine  contractions.  These  measures  are  less  disagree- 
able to  the  patient  than  manual  stimulation  through  the  abdominal  wall 
and,  on  account  of  the  tenderness  often  produced  by  this  method,  are  to  be 
preferred  when  they  produce  the  desired  result. 

Emmenagogic  Effects.  Wherever  amenorrhosa  is  due  to  pelvic  anemia,  it  is 
necessary  to  supplement  the  general  tonic  treatment  by  special  stimulating 
treatments  directed  toward  the  pelvic  organs.  This  may  be  accomplished 
by  the  cold  percussion  douche  to  the  lumbar  and  sacral  regions,  or  the  cold 
douche  to  the  lumbar  spine  and  feet.  Hot  vaginal  irrigation  is  applicable  in 
all  cases.  In  some  cases,  alternate  hot  and  cold  vaginal  irrigation  may  be 
used.  The  revulsive  sitz  is  applicable  in  cases  of  extreme  pelvic  anemia. 
It  may  be  followed  by  the  cold  lumbar  and  sacral  douche.  This  douche 
should  be  accompanied  by  considerable  percussion  and  given  for  only  a  short 
time. 

Vesical  Stimulants 

Nearly  all  sudden  thermic  applications  to  the  feet,  legs  or  trunk  produce 
contractions  of  the  dedrusor  muscle.  This  is  especially  true  of  the  cold  per- 
cussion douche  to  the  feet,  or  the  alternate  hot  and  cold  douche  to  the  feet. 
The  same  result  may  be  accomplished  by  the  sudden  application  of  the  ice 
compress  to  the  lower  abdomen  or  upper  inner  surfaces  of  the  thighs. 

Intestinal  Stimulants 

Intestinal  excitation  is  indicated  chiefly  in  constipation.  There  are  a 
large  number  of  measures  which  are  useful  in  relaxed  conditions  of  the 
intestinal  musculature.  The  patient  should  be  put  upon  some  regular  pro- 
gram. This  may  conveniently  embody  several  of  the  measures  which  are 
efficient  in  stimulating  peristalsis.  Among  these  measures,  are  the  hot 
enema,  cold  enema,  or  alternate  hot  and  cold  rectal  irrigation.  The  grad- 
uated enema  is  an  excellent  means  of  accustoming  the  patient  to  the  cold 
enema.  It  is  especially  useful  in  treating  patients  who  have  acquired  the 
enema  habit.  Of  external  applications,  there  may  be  employed  fomentations 
to  the  abdomen,  the  revulsive  compress,  hot  and  cold  spray  douche  to  the 
abdomen.  These  same  measures  may  be  applied  to  the  spine  from  the  middle 
of  the  dorsal  region  to  the  sacral  region.  The  alternate  hot  and  cold  percus- 
sion douche  to  the  feet  and  legs  also  tends  to  stimulate  peristalsis.  In 
atonic  constipation,  the  cold  rubbing  sitz  is  an  excellent  measure.  It 


INTESTINAL  STIMULANTS  179 

should  last  from  two  to  four  minutes  and  be  followed  by  the  alternate 
douche  to  the  spine  and  abdomen.  These  measures  should  be  carefully 
selected  and  utilized  according  to  the  severity  of  the  case,  special  attention 
being  given  to  the  cause.  The  above  treatments,  except  the  hot  enema 
and  fomentations  to  the  abdomen,  are  not  applicable  in  spastic  constipation 
such  as  that  accompanying  lead  poisoning.  In  this  case,  it  is  best  to  use 
fomentations  to  the  abdomen,  the  hot  sitz,  together  with  large  warm  enemata 
for  thorough  cleansing  of  the  colon  and  relief  of  the  pain.  Oil  enemata 
may  be  given  at  night  to  be  retained  over  night  or  for  several  hours. 

A  number  of  other  measures  not  hydriatic  in  nature  may  be  conveniently 
combined  with  hydrotherapeutic  treatment.  Among  these  are  the  following: 
Abdominal  massage,  spinal  nerve  stimulation,  special  exercises  to  strength- 
en the  abdominal  muscles,  vibration  to  the  abdomen,  faradic  electricity 
to  the  abdomen  and  spine,  also  sinusoidal  electricity  and  the  Morton  wave 
from  the  static  machine.  Some  of  these  forms  of  electrical  stimulation  may 
be  applied  by  means  of  a  rectal  electrode  and  an  abdominal  sponge.  All 
exercises  which  strengthen  the  abdominal  muscles  should  be  utilized,  such 
as  walking,  rowing,  horseback  riding,  bicycling,  etc. 

Counterindications  to  Excitant,  Stimulating  and  Extreme  Tonic  Measures. 

1.  Old  age. 

2.  Infancy. 

3.  Arteriosclerosis. 

4.  Acute  mania. 

5.  Tuberculosis  (pulmonary). 

6.  Emaciation. 

7.  Thin  diabetic  patients. 

8.  Bright's  disease. 

9.  Exhaustion  due  to  any  cause. 

10.  Hemorrhage. 

11.  Severe  coughing. 

12.  Asthma. 

13.  Emphysema. 

14.  Organic  heart  trouble. 

15.  Chorea. 

16.  Extreme  neurasthenia. 


SEDATIVE  EFFECTS 


Measures  which  reduce  or  check  the  over-activity  of  an  organ  or  function 
are  said  to  have  a  sedative  effect.  Since  there  are  many  organs  and 
functions,  one  might  so  elaborately  classify  sedative  effects  as  to  prove  con- 
fusing, and  so  lose  the  distinctive  principles  governing  hydriatic  sedatives. 
Any  application  must  of  necessity  affect  more  than  one  structure,  as  we 
have  learned  concerning  tonic  measures;  but  we  have  also  learned  that 
every  application  has  its  predominating  effect.  For  the  sake  of  clearness 
we  shall,  therefore,  here  discuss  only  nerve  sedatives — those  measures 
which  relieve  irritation,  nervousness,  spasm  and  convulsion,  and  are  con- 
ducive to  rest,  relaxation  or  sleep. 

The  principal  sedative  measures  may  be  classified  as  follows:  — 

I.  GENERAL  SEDATIVES. 

1.  Pure  Sedatives. 

2.  Tonic  Sedatives. 

II.  LOCAL  SEDATIVES. 

1.  For  the  relief  of  pain  (analgesics). 

2.  For  the  relief  of  parsesthesia. 

The  first  (I)  employs  mild  hypnotic,  calmative  and  antispasmodic  means, 
and  mild  tonics  almost  entirely.  The  second  (II)  must,  of  necessity,  employ 
extreme  means,  since  pain  and  abnormal  sensations  can  not  be  relieved  by 
mild  applications. 

General  Sedatives 

1.  Pure  Sedatives:    Temperatures  at  or  not  far  removed  from  neutral. 

a.  Neutral  or  warm  bath  94°  to  98°  F.,  neutral  wet  sheet  pack. 

b.  Warm  or  hot  shower,  spray,  douche  or  affusion. 

c.  Sponging — cool,  tepid  or  warm. 

d.  Heating  compress,  as  moist  abdominal  girdle,  spinal  compress,  throat 
compress,  moist  chest  pack,  etc. 

e.  Fomentations  moderately  hot,  especially  to  spine  and  abdomen. 

In  addition  to  the  above,  the  following  sedatives  are  especially  directed 
toward  decreasing  the  congestion  of  nerve  centers. 

a.  Hot  foot  bath  with  cold  to  the  head. 

b.  Cold  sitz  bath. 

c.  Cold  water  coil  to  abdomen  or  head. 

d.  Alternate  hot  and  cold  percussion  douche  to  feet. 

It  will  be  noticed  that  all  of  these  measures,  unless  it  be  the  neutral  bath, 
secure  sedation  by  combining  the  purely  sedative  effects  with  that  of  deri- 


PURE  SEDATIVES  181 

vation.  For  example,  the  hot  foot  bath  with  cold  to  the  head  produces 
sleep  and  relieves  nervousness  and  headache  by  reducing  cerebral  conges- 
tion. 

The  wet  sheet  pack  at  65°  to  70°  F. ,  given  alone  or  followed  by  a  graduated 
shower  at  95°  to  90°  F.,  is  effective  because  of  the  relief  of  cerebral  hyperemia 
which  it  produces,  combined  with  pure  sedation.  Relative  to  the  effects  of 
the  cold  wet  pack,  Baruch  l  says,  — 

"The  experiments  of  Max  Schuller  and  the  observations  of  Mary  Putnam 
Jacobi  have  so  clearly  demonstrated  the  calming  influence  of  the  wet  pack 
upon  the  cerebral  circulation  that  we  have  an  exact  basis  upon  which  this 
treatment  may  be  applied  in  many  cases  of  neurasthenia,  especially  those 
troublesome  cases  in  which  insomnia  is  a  pronounced  manifestation. 

"This  procedure  is  one  of  the  most  effective  means  of  quieting  the  entire 
nervous  system,  whether  the  irritable  condition  be  due  to  an  essential  increase 
of  reflex  excitability  or  to  a  cerebral  hyperemia.  The  pronounced  sinking 
of  the  brain  substance,  the  positive  diminution  of  the  respiration  and  heart 
beat,  the  weakening  of  the  reflex  excitability  and  of  activity  of  the  cere- 
bral ganglia  observed  in  trephined  rabbits  during  the  wet  pack,  combined 
with  the  positive  diminution  of  the  vessels  of  the  pia  mater,  represent  the 
fundamental  conditions  for  physical  calm  and  sleep.  These  are  probably 
also  present  in  man  during  the  wet  pack.  Sleep  is  accompanied  by  a  decided 
diminution  of  blood  in  the  cerebral  vessels;  indeed  the  latter  has  been 
accepted  as  an  essential  condition  for  the  production  of  sleep.  This  may 
explain  why  the  wet  pack,  properly  applied,  is  a  useful  procedure  in  the 
insomnia  of  neurasthenics." 

The  cold  sitz,  cold  coil  to  the  abdomen,  etc.,  produce  sedation  by  reducing 
congestion  of  the  sympathetic  ganglia  of  the  abdomen  and  pelvis.  Fomen- 
tations to  the  spine  withdraw  blood  from  the  spinal  cord,  and  the  heat  is  in 
itself  relaxing  and  depressant.  Heating  compresses  are  mild  derivatives  and 
combine  with  this  derivation  a  neutral  temperature.  All  antipyretic  measures 
are  in  the  nature  of  the  case  antispasmodic  and  hypnotic,  since  they  lessen 
toxemia  and  so  relieve  the  nervous  system.  Cool  sponging  is  sedative  in 
both  actual  fever  and  feverishness.  Hot  sponging  is  usually  most  effective 
in  conditions  purely  nervous.  In  acute  mania,  the  wet  sheet  pack  is  a 
most  excellent  means,  and  serves  a  double  purpose  in  restraining  the  patient 
while  applying  the  neutral  temperature. 

Indications  for  the  use  of  pure  sedatives. 

1.  Insomnia. 

2.  Agitative  neurasthenia. 

3.  Hysteria. 

4.  Mania. 

5.  Chorea  and  choreiform  diseases. 

6.  Paralysis  agitans. 

7.  Spastic  spinal  paralyses. 

8.  Epilepsy. 

9.  Locomotor  ataxia  (first  stage). 

10.  Nervousness  due  to  congestive  headache. 

11.  Clonic  and  tetanic  spasms  from  various  causes. 

1    Principles  and  Practice  of  Hydrotherapy,  p.  440. 


182  SEDATIVE  EFFECTS 

Precautions:  The  personal  factor  or  idiosyncrasy  has  much  to  do  with 
the  selection  of  a  sedative  treatment.  If  the  patient  has  taken  a  dislike  to 
a  certain  measure,  it  is  likely  to  produce  agitation  rather  than  sedation. 
Sedative  effects  are  likely  to  be  transient,  and  so  must  be  frequently 
repeated.  With  neurasthenic  patients  a  treatment  which  may  have  given 
good  results  in  a  certain  case  may  be  robbed  of  its  effect  by  some  unusual 
occurrence  which  may  seem  trivial  in  itself,  such  as  slight  alteration  in  the 
manner  in  which  it  is  given,  or  the  changing  of  an  attendant. 

2.  Tonic  Sedatives.  Insomnia  and  nervousness  may  be  due  to  a  lack  of 
normal  fatigue  such  as  follows  active  work,  especially  out  of  doors.  This  is 
particularly  true  of  those  in  sedentary  occupations,  such  as  professional, 
business  and  office  men.  These  persons  may  be  of  fairly  good  physique 
and  health  otherwise.  It  also  occurs  in  enforced  idleness,  as  after  fractures, 
operations,  etc.,  and  in  the  case  of  chronic  invalids.  The  rational  treatment 
consists  in  the  production  of  fatigue.  Where  possible,  of  course,  exercise 
in  the  open  air  is  the  most  efficient  means  of  producing  fatigue.  Mild  tonics 
are  usually  all  that  can  be  well  borne.  A  few  cases  may  be  given  even 
the  most  vigorous  treatment.  The  following  are  the  means  most  used  as 
tonic  sedatives: — 

a.  Hot  and  cold  to  the  spine. 

b.  Wet  hand  rub. 

c.  Cold  mitten  friction. 

d.  Hot  and  cold  spray,  shower  or  douche. 

e.  Neutral  faradic  tub. 

f.  Massage. 

g.  Rapid  faradic  current. 

The  Indications  have  been  outlined  above.  Some  of  the  principal  con- 
ditions requiring  tonic  measures,  in  order  to  produce  sedation  are, — 

1.  Insomnia. 

2.  Neurasthenia. 

3.  Splanchnic  neurasthenia. 

4.  Chronic  rheumatism. 

5.  Paralysis  (flaccid). 

Local  Sedatives 

1.  Analgesic  (relief  of  pain) .  For  the  purpose  of  relieving  pain,  extreme 
hot  or  cold  applications  are  absolutely  essential.  Just  which  shall  be  used 
depends  upon  the  particular  cause  and  condition  in  each  case.  Some  aim 
at  the  cause,  and  others  at  the  immediate  relief  of  the  pain  where  the  cause 
can  not  be  removed  in  a  short  time. 

For  the  relief  of  pain  hot  applications  are  usually  employed.  We  say 
that  heat  has  a  specific  pain-relieving  effect.  This  is  true;  but  it  must  be 
remembered  that  the  relief  of  the  pain  is  due  to  the  production  of  definite 
circulatory  changes  which  remove  the  cause  of  pain.  In  inflammatory 
states  the  cause  of  pain  is  to  be  found  in  pressure  upon  nerve  filaments 
occasioned  by  the  congestion  and  heightened  vascular  tension.  By  deriva- 
tion, heat  reduces  the  congestion  or  it  relaxes  the  tension,  and  thus  the 


ANALGESICS 


183 


cause  of  pain  is  removed.  When  properly  applied,  cold  may  accomplish  the 
same  results.  These  principles  are  well  illustrated  in  a  diagram  devised  by 
Lauder  Brunton.  2 

"The  diagram  (Fig.  30)  is  supposed  to  represent  the  end  of  the  finger. 
The  small  star  indicates  the  point  of  irritation,  e.  g.,  a  prick  by  a  thorn. 
The  line  in  the  center  of  each  finger  is  intended  to  represent  the  nerve  go- 
ing to  the  injured  part;  and  at  the  side  of  each  figure  is  an  artery  and  vein 
connected  by  a  capillary  network.  In  a  the  capillary  network  around  the 
seat  of  irritation  is  seen  to  be  much  congested;  the  nerve-filaments  are  thus 
pressed  upon,  and  pain  is  occasioned;  6  represents  the  condition  of  the  finger 
after  the  application  of  cold  to  the  arm  or  hand.  In  consequence  of  the 
contraction  of  the  afferent  arteries  the  finger  becomes  anemic;  no  pressure 


Fig.  30.     Diagram  to  show  the  effects  of  heat  and  cold  in  lessen- 
ing the  pain  of  inflammation.     (Brunton) 

is  exerted  on  the  nervous  filaments,  and  pain  is  alleviated;  c  represents  the 
finger  after  it  has  been  encased  in  a  warm  poultice;  the  capillary  network 
at  the  surface  of  the  finger  is  dilated,  and  the  blood  is  thus  drawn  away 
from  the  seat  of  irritation,  and  the  pain  therefore  relieved." 

For  the  relief  of  pain  the  following  treatments  are  useful: — 

a.  Very  hot  fomentations. 

b.  Hot  immersion,  foot  bath,  sitz,  etc. 

c.  Hot  pack,  local  or  full  blanket  pack. 

d.  Hot  enema. 

e.  Extreme  cold, —as  ice  bag,  ice  compress  to  painful  part  or  over  artery 
supplying  the  part,  use  of  ice  water  or  cracked  ice  by  mouth. 

f .  Cold  immersion,  as  of  a  hand  or  foot,  sitz  bath,  etc. 

g.  Derivation. 

h.  Fluxion  by  alternate  extreme  hot  and  cold  applications. 

The  Indications  for  the  use  of  pain  relieving  measures  are  numerous. 

1.  Pain  of  deep  seated  inflammation. 

2.  Pain  of  superficial  inflammation. 

3.  Gastric  ulcer. 

4.  Rectal  ulcer. 

5.  Hemorrhoids. 


2    Therapeutics  of  the  Circulation,  p.  174. 


184  SEDATIVE  EFFECTS 

6.  Toxic  neuralgia. 

7.  Inflammatory  neuralgia. 

8.  Tenesmus— rectal  or  vesical. 

9.  Dysmenorrhea. 

10.  Colic— renal,  biliary,  intestinal. 

11.  Burns. 

12.  Sprains,  bruises,  etc. 

13.  Fractures. 

2.  Relief  of  Paraesthesias  (abnormal  sensations,  such  as  burning,  smart- 
ing, itching,  crawling  sensations). 

a.  Ice  bag. 

b.  Immersion  in  cold  water  or  ice  water. 

c.  Very  hot  sponging. 

d.  Stupes. 

e.  Weak  chemical  irritants,  as  neutral  saline  bath,  bicarbonate  of  soda 
bath,  saline  sponging,  alcohol  rub,  witch-hazel  rub,  menthol  compress. 

f.  Short  sweating  bath  followed  by  tub  shampoo  and  cool  bath. 

Indications : — 

1.  Pruritis  from  various  causes. 

2.  Hives  and  heat  rashes. 

3.  Formication. 

4.  Numbness  and  tingling. 

5.  Burning  and  smarting. 

Insomnia 

Baruch  not  inaptly  styles  the  insomnia  of  neurasthenia  an  opprobrium  med- 
icorum.  If  one  were  to  form  an  opinion  from  the  bad  effects  of  medicinal 
treatment  and  the  frequency  with  which  such  treatment  is  used,  the  condi- 
tion is  indeed  a  discredit  to  scientific  medical  practice.  The  insomnia  ac- 
companying neurasthenia  is  due  to  a  peculiar  association  of  nerve  exhaustion 
with  hyperirritability.  Doubtless  nerve  poisons  from  auto-intoxication  play- 
a  large  part  in  the  causation.  It  would  seem  that  congestion  of  the  cere- 
bral and  spinal  centers  is  also  a  cause  of  nerve  irritability  and  sleeplessness. 
It  is  present  in  the  majority  of  cases. 

Because  of  the  lack  of  nerve  tone  general  tonic  treatment  as  outlined  for 
neurasthenia  is  quite  as  essential  as  sedative  measures  which  aim  principally 
at  the  insomnia.  In  many  patients,  lack  of  normal  fatigue  is  the  chief,  if 
not  the  sole  cause.  In  such  cases  a  mild  or  even  a  vigorous  tonic  treatment 
given  about  an  hour  before  bedtime  will  produce  the  best  results.  With 
some  persons  brisk  exercise  to  the  point  of  moderate  fatigue,  taken  just 
before  retiring,  will  accomplish  the  same  results. 

We  have  principally  to  consider  the  insomnia  due  to  increased  reflex  excit- 
ability and  unusual  irritability  of  the  nerve  centers.  The  condition  may  be 
perpetuated  long  after  removal  of  the  first  cause  has  been  affected.  This 
is  especially  true  of  those  patients  who  "can't  go  to  sleep"  because  of  con- 
stant worrying  about  their  inability  to  sleep.  These  persons  are  the  bane 
of  the  neurologists  life.  They  are  exceedingly  introspective  and  often 
almost  hysterical.  In  order  to  decrease  reflex  excitability  it  is  necessary  to 


INSOMNIA  185 

remove  as  far  as  possible  all  external  stimuli  and  at  the  same  time  decon- 
gest  the  spinal  and  cerebral  centers. 

For  these  purposes  the  ideal  means  is  found  in  the  neutral  bath  or  pack. 
The  body  is  enveloped  in  a  non-irritating  medium,  the  skin  is  slightly  warmed 
and  both  the  skin  and  the  skeletal  muscles  relaxed.  The  temperature  of 
the  neutral  bath  should  be  not  less  than  94°  F.  and  it  is  often  better  to  use 
water  a  little  warmer,  say  96°  or  97°  F.,  since  the  warmth  secures  a  full 
relaxation.  The  bath  should  be  given  in  a  quiet,  fairly  warm  room  and  last 
for  fifteen  or  twenty  minutes  to  a  half  hour  or  longer.  The  disturbing 
effect  of  draughts  may  be  avoided  by  stretching  a  sheet  across  the  top  of  the 
tub.  It  is  well  to  lower  the  temperature  of  the  water  two  or  three  degrees 
just  at  the  close  of  the  bath.  A  patient  should  never  be  put  into  a  neutral 
bath  with  cold  feet.  All  parts  of  the  body  should  be  warm  beforehand. 
The  neutral  bath  or  warm  bath  has  an  effect  similar  to  the  neutral  pack  in 
causing  the  sinking  of  the  brain  substance.  The  rationale  of  the  wet  sheet 
pack  has  already  been  explained.  With  many  patients  it  is  the  most  effi- 
cient means  that  can  be  used.  By  means  of  woolen  blankets  the  covering 
of  the  pack  can,  by  an  observant  nurse,  be  so  regulated  as  to  be  kept  con- 
stantly at  the  neutral  stage.  The  feet  should  be  more  warmly  covered  than 
the  upper  part  of  the  body.  An  exceedingly  restless  patient  who  has  had 
but  little  sleep  for  weeks  may  sleep  for  hours  or  all  night  in  a  neutral  pack. 

The  salutary  effects  of  a  drugless  sleep  are  felt  all  the  next  day.  There 
is  not  the  usual  after-tendency  to  drowsiness.  The  patient  feels  like  him- 
self. Quite  the  contrary  condition  follows  the  rest  obtained  by  trional, 
the  bromides  and  other  hypnotics.  The  patient  is  likely  to  be  drowsy  during 
the  succeeding  forenoon.  For  this  reason  medicinal  soporifics  often  defeat 
their  own  end.  The  patient  must  be  kept  awake  during  the  daytime  so  that 
natural  fatigue  may  result  and  thus  the  system  demand  rest  and  sleep. 

There  are  many  other  measures  which  will  be  found  useful.  The  milder 
types  of  insomnia  respond  very  quickly  to  a  set  of  three  fomentations  to  the 
spine  given  just  at  bedtime.  If  thought  best,  this  may  be  followed  by  a  light 
rub  either  to  the  spine  alone  or  to  the  body  generally.  The  tepid  spinal  affu1 
sion  has  an  effect  similar  to  the  spinal  fomentation.  It  should  be  applied  to 
the  lower  dorsal  and  lumbar  spine.  Some  cases  of  insomnia  seem  to  be  due 
solely  to  cerebral  hyperemia.  This  is  common  in  brain  workers.  In  these 
cases  the  feet  are  almost  invariably  cold.  If  the  unbalance  is  extreme,  a 
very  hot  foot  or  leg  bath  with  cold  to  the  head  should  be  given  for  about 
ten  or  fifeen  minutes.  This  should  be  followed  by  an  alternate  hot  and  cold 
percussion  douche  to  the  feet.  Sometimes  the  latter  will  accomplish  the 
results  as  well  when  given  alone  as  following  the  hot  foot  bath.  The  vigor- 
ous fluxion  produced  in  the  feet  by  the  combination  of  percussion  with  ther- 
mic stimuli  results  in  more  permanent  cerebral  derivation  than  a  hot  foot 
bath  alone. 

The  moist  abdominal  girdle  is  an  excellent  adjunct  to  a  sedative  treat- 
ment. As  shown  by  the  experiments  of  Schuller,  it  lessens  the  filling  of  the 
cerebral  vessels.  It  may  be  used  after  any  of  the  treatments  recommended 
above.  It  should  be  worn  all  night.  If  properly  applied,  it  will  be  dry  or 
nearly  dry  by  morning.  If,  because  it  does  not  promptly  " warm  up, "  chilli- 


186  SEDATIVE  EFFECTS 

ness  results,  it  must  be  removed.     With  some  patients  it  produces  "fidgets" 
and  for  this  reason  must  be  discontinued. 

Of  tonic  sedatives  designed  to  aid  in  producing  normal  fatigue,  the  follow- 
ing may  be  used  in  insomnia:  Hot  and  cold  to  the  spine,  the  cold  mitten 
friction,  the  alternate  spray  or  a  short  electric  light  bath  followed  by  a 
spray.  The  neutral  faradic  tub  followed  by  a  short  massage  gives  good 
results.  Either  one  may  be  used  alone.  The  mild  exercise  occasioned  by 
dry  faradism  or  the  faradic  tub  is  often  sufficient  to  induce  sleep.  In  the 
management  of  most  cases  of  neurasthenic  insomnia  it  is  best  to  give  a 
tonic  treatment  in  the  forenoon,  reserving  sedative  treatment  and  massage 
for  the  afternoon  or  evening.  Following  the  plans  outlined  above,  or  simi- 
lar methods,  carefully  adapting  the  treatment  to  the  needs  of  the  particular 
case  under  observation,  can  not  fail  to  produce  cure  provided  the  patient 
fully  commits  himself  to  the  judgment  of  the  physician  and  remains  long 
enough  to  secure  permanent  results. 


Chorea 

The  common  or  Sydenham's  chorea  is  the  form  considered  here.  This  is  the 
type  which  is  associated  with  rheumatic  fever  and  endocarditis,  occurring  from 
five  to  twenty-five  years  of  age  and  most  frequent  between  the  ages  of  five 
and  fifteen.  It  may  also  occur  during  pregnancy.  The  cause  is  not  definitely 
known.  The  chorea  movements  are  sharp,  decisive  and  irregular. 

The  condition  demands  a  period  of  absolute  rest  in  bed  with  freedom  from 
all  excitement.  Chorea  can  be  best  treated  in  an  institution  away  from 
friends  and  relatives.  All  possible  sources  of  auto-intoxication  such  as  bad 
diet  and  constipation  should  receive  special  attention.  The  hydriatic  man- 
agement, while  very  simple,  is  of  great  importance.  During  the  period 
when  perfect  rest  is  demanded,  pure  sedatives  should  be  used.  Of  these  the 
neutral  bath  is  most  efficient.  It  should  be  given  once  or  twice  a  day  and 
prolonged  from  twenty  minutes  to  an  hour.  The  bath  should  feel  warm, 
having  a  temperature  of  96°  or  97°  F.  The  wet  sheet  pack  may  also  be  used, 
being  kept  at  the  neutral  stage.  It  should  last  about  the  same  length  of  time 
as  the  bath,  or  the  patient  may  be  allowed  to  sleep  in  it  and  be  removed 
later  with  a  wet  hand  rub.  After  some  improvement  has  been  secured,  in 
a  week  or  ten  days,  other  sedative  means  which  combine  with  them  mild 
tonic  effects  may  be  used.  These  should  at  first  be  very  mild,  such  as  a  wet 
hand  rub,  tepid  sponging  and  the  neutral  spinal  affusion  or  pour.  The  heat- 
ing abdominal  compress  or  moist  abdominal  bandage  may  give  good  results. 
Fomentations  to  the  spine,  followed  by  the  cold  heating  compress  for  15  to 
20  minutes  is  an  excellent  sedative.  During  the  entire  course  of  treatment, 
the  neutral  baths  or  packs  should  be  continued.  When  convelescence  is  well 
established  the  cold  mitten  friction,  cold  towel  rub,  graduated  and  alternate 
sprays  may  be  used,  also  light  massage.  All  of  these  measures  serve  to 
remedy  the  anemia;  even  the  neutral  bath  is  helpful  in  this  direction.  The 
beneficial  effects  of  out  door  life  in  the  country,  sunshine  and  fresh  air  can 
not  be  overestimated. 

In  case  chorea  is  complicated  by  endocarditis,  the  same  system  of  treat- 


SPASTIC  PARALYSES  187 

ment  should  be  followed  as  outlined  for  the  endocarditis  of  rheumatism.  The 
only  alteration  necessary  is  the  substitution  of  sedative  treatment  once  or 
more  daily  for  some  of  the  tonic  such  as  the  cold  mitten  friction  used  in 
rheumatic  endocarditis. 


Paralysis  Agitans 

While  this  is  considered  an  incurable  affection,  the  patient  may  be  much 
benefited  and  the  progress  of  the  disease  stayed  for  quite  long  periods  of 
time  by  general  hygienic  management  combined  with  sedative  and  mild 
tonic  hydrotherapy.  The  measures  recommended  above  for  chorea  are  all 
helpful  in  shaking  palsy.  Dana3  especially  recommends  the  lukewarm  (neu- 
tral) bath  and  mild  massage.  Oppenheim4  has  seen  improvement  following 
the  use  of  the  faradic  bath.  Vibrating  chairs  or  vibrating  machines  adjusted 
to  give  a  fine  rapid  movement  may  show  good  results.  Out  door  life  in  the 
woods  and  country  are  especially  beneficial. 


Spastic   Spinal  Paralyses 

There  are  a  number  of  lesions  of  the  cord  which  ultimately  result  in 
degeneration  of  the  upper  motor  neuron,  chiefly  in  the  lateral  column. 
The  inhibitory  control  from  the  cerebral  cortex  being  cut  off,  a  condition  of 
spastic  paralysis  results,  i.  e.,  a  loss  of  control  associated  with  rigidity  and 
spasticity  of  the  muscles.  Such  a  condition  occurs  after  various  forms  of 
myelitis,  especially  a  transverse  myelitis,  also  in  amyotrophic  lateral  scle- 
rosis. If  there  is  an  acute  onset  as  by  trauma  or  inflammation,  as  fre- 
quently occurs  in  myelitis,  the  patient  must  be  put  to  rest,  either  absolute 
or  partial,  according  to  the  nature  and  needs  of  the  case.  In  some  cases 
gentle  spinal  extension  should  be  used  for  some  weeks  and  perfect  quiet 
observed.  In  other  cases,  the  patient  may  be  allowed  to  move  about  the 
bed.  During  this  time,  spinal  fomentations  may  be  applied  twice  daily,  fol- 
lowed by  the  heating  spinal  compress.  The  warmth  of  the  limbs  should  be 
maintained  by  the  hot  foot  bath  or  hot  water  bottles.  It  is  necessary  that 
the  patient  be  given  tonic  treatment  to  keep  up  the  nutrition  and  invigor- 
ate the  circulation.  These  must,  however,  be  quite  mild,  such  as  the  wet 
hand  rub  and  moderately  cold  mitten  frictions.  Later,  light  massage  to  the 
limbs  may  be  used. 

As  soon  as  the  necessity  for  absolute  rest  is  past,  in  the  chronic  stage 
when  spasticity  becomes  marked,  nothing  has  proven  so  helpful  as  the  pro- 
longed neutral  or  warm  bath.  In  those  cases  in  which  cure  is  possible  this 
measure  is  almost  specific.  The  patient  should  be  made  very  comfortable  in 
the  tub  by  using  a  sheet  hammock,  rubber  pillows,  etc.  The  temperature 
of  the  water  should  be  from  94C  or  95°  to  97°  F.  It  must  feel  slightly  warm 
to  the  patient.  At  first,  the  bath  may  be  twenty  minutes  to  an  hour  in 
length,  gradually  increasing  the  time  up  to  three  or  four  hours  of  continuous 
immersion  daily.  Even  six  hours  in  the  neutral  bath  may  prove  beneficial. 
The  salutary  effects  are  manifest  in  a  lessened  degree  of  rigidity,  the  limbs 

3  Text  Book  of  Nervous  Diseases. 

4  Diseases  of  the  Nervous  System. 


188  SEDATIVE  EFFECTS 

become  more  supple  and  can  be  separated  to  a  greater  extent.  In  order  to 
obtain  any  permanent  benefit,  the  patient  must  submit  to  treatment  for 
many  months. 

In  the  subacute  stage,  positive  galvanism  to  the  spine  may  be  useful. 
During  this  time  mild  alternating  hot  and  cold  applications  may  be  used  to 
the  part  of  the  spine  affected.  Later  in  the  disease,  prolonged  neutral  baths 
give  better  results. 

Locomotor  Ataxia 

In  the  treatment  of  tabes  dorsalis  we  are  concerned  chiefly  with  the  first 
two  stages,  the  initial  or  pre-ataxic  and  the  ataxic.  In  the  paralytic  or 
third  stage,  there  is  little  that  can  be  done. except  to  make  the  patient  com- 
fortable and  treat  symptoms  as  they  arise. 

In  the  pre-ataxic  stage  the  patient  must  be  put  to  rest.  This  may  be 
accomplished  by  restricting  or  prohibiting  exercise.  It  is  usually  best  to 
proscribe  exercise  altogether  for  a  time.  The  wheel  chair  may  be  used  or, 
if  thought  best,  the  patient  may  be  put  to  bed  for  two  or  three  months. 
Simple,  regular  habits  are  imperative.  During  the  period  of  rest,  the  patient 
may  be  treated  by  fomentations  to  the  spine,  cold  mitten  frictions  and  the 
warm  bath.  Dana  recommends  that  this  latter  be  given  for  ten  to  twenty 
minutes  daily  and  followed  by  a  single  cold  pour  to  the  spine  and  rubbing. 
The  object  of  treatment  during  this  stage  is  to  keep  up  the  patient's 
general  nutrition  and  afford  rest,  both  mental  and  physical,  so  as  to  relieve 
the  tax  on  the  spinal  nerves. 

If  the  progress  of  the  disease  can  be  stayed,  the  treatment  outlined  for 
the  ataxic  stage  may  be  ventured  upon,  beginning  mildly.  The  Fraenkel 
exercises  may  now  be  begun.  These  should  at  first  consist  of  the  more 
simple  movements  and  the  effort  restricted  to  a  few  minutes.  Later  on,  as 
co-ordination  improves,  they  may  be  more  prolonged  and  made  up  of  more 
complicated  exercises. 

Vigorous  spinal  tonics  should  be  used  during  the  ataxic  stage  unless  the 
patient  is  becoming  rapidly  worse.  Alternate  hot  and  cold  to  the  spine  by 
means  of  the  fomentation  and  ice  may  be  used  daily,  or  this  may  alternate 
with  the  Charcot  (cold  percussion)  douche  to  the  spine  or  hot  and  cold  douche 
to  the  spine.  These  applications  should  be  persisted  in  for  months.  The 
long  static  spark  to  the  lower  spine  and  legs  may  be  used  at  the  same  time, 
say  thrice  weekly.  Galvanic  currents  are  also  beneficial.  It  must  be  remem- 
bered that  not  all  cases  are  susceptible  of  any  marked  improvement.  The 
plans  outlined  above  have  proven  very  satisfactory  in  the  hands  of  many 
neurologists.  Nearly  all  agree  that  mercurial  treatment  is  harmful  unless 
symptoms  of  active  syphilis  still  exist.  Even  in  this  case  bad  results  have 
frequently  been  reported,  and  some  observers  believe  that  antisyphilitic 
medication  may  be  the  direct  cause  of  tabes. 

For  the  arthritic  complications  (Charcot's  joint)  alternate  hot  and  cold 
applications  for  the  purpose  of  maintaining  the  local  nutrition  and  improv- 
ing the  circulation  will  be  found  helpful.  These  may  be  given  by  means  of 
the  revulsive  compress,  alternate  pours,  or  alternate  hot  and  cold  immer- 


HYPERTHYROIDISM  189 

sions.     For  painful  joints,  very  hot  fomentations  may  be  given,  followed  by 
the  heating  compress. 

The  treatment  of  the  various  crises  is  unsatisfactory.  They  may  at  times, 
be  relieved  by  local  hot  applications.  All  forms  of  treatment,  including 
hypnotics,  may  fail.  The  same  may  be  said  of  the  lightning  pains.  Build- 
ing up  the  general  vitality  of  the  patient  will  tend  to  remedy  these  distressing 
conditions. 


Parenchymatous  Goiter 

The  pathology 5  and  morbid  physiology  of  parenchymatous  or  exophthal- 
mic goiter  must  be  fully  understood  if  medical  treatment  is  to  be  conducted 
to  produce  the  best  possible  results.  Exophthalmic  goiter  is  now  considered 
to  be  due  to  hypertrophy  and  hyperactivity  of  the  thyroid  gland.  The  dis- 
ease is  better  described  as  hyperthyroidism.  The  thyroid  is  one  of  the  duct- 
less glands  producing  an  internal  secretion.  The  exact  chemical  nature  of 
this  secretion  is  not  known.  It  is  believed  to  be  closely  associated  with 
some  iodine  compound.  It  is  one  of  that  class  of  substances  known  as  chemi- 
cal messengers  or  harmones.  It  exercises  a  special  influence  over  certain 
functions.  In  infancy,  the  absence  of  the  gland  is  marked  by  the  condition 
known  as  cretinism,  in  which  both  the  mind  and  the  body  remain  in  an  unde- 
veloped state.  In  adult  life,  atrophy  or  removal  of  the  gland  produces  the 
condition  known  as  myxoadema,  or  cachexia  strumipriva.  In  these  conditions, 
mental  activity  is  below  par,  cerebration  is  exceedingly  slow  and  all  bodily 
movements  are  deliberate  and  physical  activity  much  depressed.  The  oppo- 
site condition,  known  as  hyperthyroidism,  caused  either  by  hypertrophy  of  the 
glandular  tissue  or  by  giving  large  doses  of  thyroid  extract,  produces  a 
train  of  symtoms  just  the  opposite  of  the  above.  The  patient  is  nervous, 
restless,  irritable  and  may  be  subject  to  insomnia.  There  is  a  fine  temorof 
the  fingers  when  the  hand  is  held  away  from  any  support  with  the  digits 
spread.  During  the  early  part  of  the  disease,  mental  activity  is  excessive, 
ideation  is  rapid  and  all  the  brain  functions  are  increased  in  acuity.  If 
intoxication  becomes  intense,  the  pulse  may  be  very  rapid,  running  from 
100  or  120  to  160  or  more  per  minute;  the  skin  is  usually  warm  and  moist, 
being  covered  with  perspiration  the  most  of  the  time.  The  blood  vessels 
are  dilated.  Catabolic  changes  are  increased  and  hastened  as  shown  by  the 
fever  and  increase  in  the  excretion  of  nitrogen.  There  is  a  feeling  of  lan- 
'  guor;  and  asthenia  may  become  very  marked.  In  the  gland  itself,  the  col- 
loid material  is  deficient  in  amount,  there  is  an  increase  in  the  number  of 
secreting  cells,  even  to  the  filling  of  the  alveoli  with  cells;  the  bloodvessels 
of  the  gland  are  dilated  and  may  be  increased  in  number.  Later,  the  par- 
enchymatous cells  degenerate  (cytolysis)  liberating  a  large  amount  of  thy- 
roid secretion;  the  most  aggravated  symptoms  may  be  present  while  this  is 
going  on.  The  stethoscope  applied  over  the  gland  frequently  detects  a  sys- 
tolic bruit.  Owing  to  this  increased  vascularity  and  the  hypertrophy  of  the 
parenchymatous  tissue,  the  thyroid  is  enlarged.  Later  in  the  disease,  the 
eyes  become  prominent,  the  lids  are  closed  with  difficulty  and  the  eyes  feel 

5    See  articles  on  goiter  among  Collected  Papers  by  the  Staff  of  St.  Mary's  Hospital,  1905-1909. 


190  SEDATIVE  EFFECTS 

dry.      It  is  supposed  that  the  exophthalmia  is  due  to  dilitation  of  the  blood 
vessels  in  the  orbit. 

It  will  be  seen  that  these  conditions  set  forth  the  necessity  for  treatment 
directed  toward  decreasing  and  depressing  the  activity  of  the  thyroid  gland. 
In  the  spontaneous  cure  of  this  condition,  the  colloid  material  increases  in 
amount,  producing  pressure  upon  the  parenchymatous  cells,  thus  causing 
their  atrophy.  The  increase  of  the  fibrous  stroma  of  the  gland  has  the  same 
effect.  In  these  facts  lies  the  rationale  of  the  beneficial  action  of  the  X-Ray. 
It  has  a  specific  effect  in  destroying  or  causing  atrophy  of  highly  differen- 
tiated tissue,  while  it  favors  the  production  of  connective  tissue.  X-Ray 
exposures  should  not  be  given  so  frequently  as  to  cause  unduly  rapid  disin- 
tegration of  the  secreting  cells,  in  which  case  thyroid  intoxication  may  en- 
sue. The  vascularity  of  the  gland  must  also  be  decreased. 

Albert  Kocker  makes  the  following  statements6  "By  reducing  the  hyper- 
trophic  thyroid  tissue  or  reducing  its  blood  supply,  we  reduce  the  possibility 
of  too  extensive  reaction  to  the  primary  cause  and  also  enable  the  gland  to 
adapt  itself  to  counteract  new  outbreaks  of  primary  causes  which  a  nervous 
subject  can  easily  show. 

"The  fact  that  increased  vascularization  is  indispensable  for  the  develop- 
ment of  the  disease  also  proves  that  what  reduces  vascularization  prevents 
its  development." 

At  the  same  time,  it  is  necessary  to  slow  the  heart  rate  and  restore  the 
blood  vessels  to  their  normal  tone.  While  all  cases  will  not  respond  to  the 
same  treatment,  or  even  to  different  measures  arranged  in  different  ways, 
yet  in  general,  the  treatment  should  consist  of  the  means  making  up  the 
following  program:  An  ice  cap  should  be  placed  over  the  goiter  almost  con- 
tinuously or  for  thirty  minutes  to  an  hour  from  two  to  five  times  a  day. 
These  cold  applications  reflexly  contract  the  blood  vessels  of  the  gland,  thus 
decreasing  its  vascularity  and  the  amount  of  blood  in  the  gland.  They  also 
tend  to  inhibit  or  depress  the  glandular  activity,  decreasing  the  formation  of 
the  internal  secretion.  At  the  same  time,  an  ice  bag  should  be  applied  to 
the  precordia  in  much  the  same  manner  and  for  the  same  length  of  time  as 
the  ice  bag  to  the  goiter.  It  may  be  found  convenient  to  alternate  these 
applications,  keeping  the  ice  bag  over  the  goiter  for  thirty  minutes,  then 
applying  it  to  the  heart  for  the  same  length  of  time,  then  reapplying  it  to 
the  goiter,  these  alternations  being  continued  more  or  less  during  the  entire 
day.  The  vaso-dilitation  and  warm,  moist  skin  require  some  treatment 
which  will  restore  the  vessels  to  their  normal  tone  and  check  the  over-activ- 
ity  of  the  sweat  glands.  This  is  best  accomplished  by  the  cold  mitten  friction. 
It  should  be  given  from  one  to  three  times  daily.  Many  of  the  principles 
governing  the  treatment  of  organic  heart  disease  are  involved  in  the  treat- 
ment of  parenchymatous  goiter.  The  cold  friction,  by  restoring  the  peri- 
pheral vessels  to  their  normal  tone,  assists  the  heart  action  and  so  reduces 
the  rate. 

The  patient  should  be  kept  at  absolute  rest  until  the  pulse  has  returned 
to  nearly  normal.  Freedom  from  mental  excitement  and  worry  are  fully 

6  Surgical  Treatment  of  Exophthalmic  Goiter — Journal  of  American  Medical  Association, 
October  12,  1907,  pp.  1242-3. 


THE  RELIEF  OF  PAIN  191 

as  necessary  as  physical  rest.  In  fact,  overtaxation  of  the  mental  powers, 
nervous  excitement,  etc.,  are  often  contributing  factors  in  the  causation  of 
the  disease  and  may  constitute  the  immediate  cause.  In  some  cases,  it 
may  seem  best  to  employ  some  of  the  sedative  measures,  such  as  fomenta- 
tions to  the  spine  and  the  neutral  bath.  Usually  both  of  these  treatments  are 
counterindicated.  If  the  feet  remain  cold  much  of  the  time,  the  alternate 
hot  and  cold  foot  bath  or  alternate  hot  and  cold  douche  to  the  feet  should 
be  used. 

We  have  yet  to  see  a  case  which  has  not  been  brought  to  a  successful 
issue  when  these  measures  have  been  applied  early,  and  have  seen  complete 
restoration  in  cases  that  have  come  under  treatment  later  in  the  disease 
when  the  pulse  reached  160,  while  the  patient  was  exceedingly  nervous  and 
unable  to  sleep,  and  there  was  very  marked  exophthalmia  together  with  a 
large  goiter.  Those  cases  which  come  on  after  thirty  respond  much  more 
readily  to  treatment  than  when  the  disease  occurs  in  younger  adults  or 
under  twenty  years  of  age.  But  it  is  also  true  there  is  a  natural  tendency 
to  recovery  among  young  adults,  nineteen  out  of  twenty  recovering  with- 
out much  treatment  but  rest.  Hyperthyroidism  beginning  in  persons  from 
eighteen  to  twenty  years  of  age  is  likely  to  run  a  course  of  three  or  four 
years  and  end  in  a  spontaneous  cure.  Operative  interference  will  be  much 
less  frequently  necessary  where  these  measures — rest,  hydrotherapy,  etc. — 
are  given  a  thorough  trial  by  those  experienced  in  their  use. 


The  Relief  of  Pain 

Deep  Seated  Inflammations 

Those  treatments  which  have  already  been  outlined  for  the  relief  of  con- 
gestion and  inflammation  in  internal  organs  are  also  most  effective  in  reliev- 
ing the  pain  occasioned  by  the  inflammation.  In  the  majority  of  cases, 
derivation  by  collateral  heat,  together  with  cold  directly  over  the  part,  is 
used  to  relieve  the  congestion  and  pain.  In  others,  hot  applications  alone 
are  used.  This  is  true  of  pleurisy,  in  which  cold  applications  increase  the 
pain.  In  many  cases  the  pain  is  relieved  best  by  very  hot  applications 
applied  directly  over  the  seat  of  the  pain.  1^  has  already  been  mentioned 
that  cold  may  be  used  over  an  inflammatory  process  in  soft  tissue,  while  in 
bony  parts  it  is  necessary  to  use  hot  applications  directly  over  the  seat  of 
the  pain.  In  the  case  of  osteomyelitis  and  usually  in  mastoiditis,  cold  appli- 
cations or  the  ice  bag  applied  over  the  inflamed  part  increases  the  pain. 
When  an  inflammation  has  gone  on  to  the  formation  of  an  abscess,  cold 
applications,  especially  the  ice  bag,  have  very  little  influence  on  the  pain 
as  far  as  relieving  it  is  concerned,  and  may  make  it  worse.  Fomentations 
over  an  abscess  may  relieve  the  pain  for  a  time,  but  this  does  not  last  as 
long  as  the  relief  afforded  previous  to  the  formation  of  the  abscess. 

In  order  to  decrease  the  throbbing  pain  of  an  inflammatory  process  or 
collection  of  pus  in  the  bone,  it  is  best  to  apply  the  ice  bag  over  the  large 
artery  supplying  the  inflamed  part.  The  relief  of  the  pain  in  this  case  is 
brought  about  chiefly  by  reducing  the  congestion.  If,  at  the  same  time,  a 


192  SEDATIVE  EFFECTS 

very  hot  fomentation  is  applied  over  the  part,  the  effect  is  intensified  by  the 
specific  pain-relieving  action  of  the  heat. 

Superficial   Inflammation 

In  the  early  stage  of  a  superficial  inflammation,  a  prolonged  cold  appli- 
cation is  usually  very  effective  in  relieving  the  pain.  This  should  be 
accomplished  by  immersion  in  cold  water  or  ice  water  or  by  the  use  of  the 
ice  bag.  Later  on,  it  will  be  found  that  very  hot  applications  more  effect- 
ively relieve  the  pain.  Either  very  hot  fomentations  or  hot  immersion  may 
be  used.  Sometimes  the  neutral  or  warm  pour  is  very  grateful,  there  seenv- 
ing  to  be  an  added  effect  from  the  affusion  that  is  not  obtained  by  quiet 
immersion.  The  production  of  fluxion  by  alternate  extreme  hot  and  cold 
immersion  is  productive  of  good  results  where  there  is  not  much  throbbing 
pain. 

Gastric  or  Duodenal  Ulcer 

It  is  often  the  case  that  the  pain  is  worse  during  the  time  that  there  is  lit- 
tle, if  any,  hemorrhage  from  the  ulcerated  surface.  In  case  hemorrhage  of 
any  moment  occurs,  it  is  necessary  to  use  some  cold  applications,  such  as 
cracked  ice  by  mouth,  or  the  ice  bag  over  the  stomach.  Otherwise,  the  pain 
is  best  relieved  by  very  hot  fomentations  applied  to  the  epigastrium,  or  the 
full  hot  trunk  pack.  These  applications  may  be  followed  by  either  the 
moist  abdominal  girdle  or  by  the  heating  wet  sheet  trunk  pack.  The  effect 
of  these  applications  is  to  relax  the  musculature  of  the  stomach  and  so,  by 
decreasing  peristalsis,  relieve  the  pain  incident  to  muscular  contractions. 

Rectal  Ulcer 

The  same  principles  apply  here  as  above.  The  pain  is  most  effectively 
relieved  by  applications  which  relax  the  bowel,  thus  decreasing  the  move- 
ment and  consequent  irritation  of  the  ulcerated  surface.  This  may  be 
accomplished  by  the  hot  enema  or  fomentations.  Usually  the  hot  sitz-bath 
is  much  more  effective. 

Hemorrhoids 

Two  different  plans  may  be  followed  in  relieving  the  pain  occasioned  by 
rectal  varicose  vains.  Very  Jiot  applications  are  effective  in  relieving  the 
pain,  but  these  have  no  tendency  to  decrease  the  size  of  the  hemorrhoids. 
On  the  contrary,  they  may  increase  the  dilitation  of  the  veins,  stasis  of 
blood  and  consequent  pain.  Of  the  hot  applications  which  may  be  used,  the 
very  hot  sitz-bath  is  most  effective.  In  case  facilities  for  this  are  not  at 
hand,  fomentations  may  be  used. 

For  permanent  results,  we  prefer  cold  applications,  such  as  the  prolonged 
cold  sitz-bath,  ice  bag  to  the  perineum,  also  the  hot  and  cold  perineal  spray. 
To  be  effective,  these  treatments  should  be  repeated  once  or  twice  daily  for 
several  weeks.  The  temperature  of  the  cold  sitz-bath  may  be  decreased  grad- 
ually as  the  patient  is  able  to  bear  it. 

Neuralgia 

The  classification  of  neuralgias  into  two  types  has  aided  in  the  treatment 


NEURALGIA  193 

of  this  condition.  Simple  neuralgias,  not  due  to  pressure  from  tumors, 
exostoses,  etc.,  we  have  classified  as  either  toxic  or  inflammatory.  By  the 
term  toxic,  we  designate  such  neuralgias  as  are  due  to  rheumatic  (uric  acid) 
diathesis,  or  some  form  of  auto-intoxication.  The  essential  element  in  the 
causation  of  this  form  of  neuralgia  is  the  circulation  of  toxins  in  the  body, 
or  the  accumulation  of  toxins  about  nerve  centers  or  nerve  trunks. 

By  the  term  inflammatory  neuralgia,* we  understand  such  conditions  as  are 
due  to  actual  inflammation,  usually  such  inflammations  as  pass  through  the 
regular  stages  of  an  inflammatory  process,  from  acute  to  chronic.  It  may 
often  be  difficult,  impossible,  and  in  some  cases,  unnecessary  to  make  these 
distinctions.  It  will  be  readily  understood  that  some  of  the  changes  occur- 
ring: in  an  ordinary  inflammation  are  produced  by  the  accumulation  of  toxins 
about  nerve  trunks.  Local  edema  of  tissues  occurs  in  both  cases. 

1.  Toxic   Neuralgia.     Where    there    is    a    local    accumulation   of   toxins 
about  a  nerve    trunk,    it    appears    that   hot    applications    most   effectually 
relieve  the  pain  while  cold  increases  the  pain.     Nitrogenous  extractives  and 
other  nitrogenous  toxins  are  soluble  with  difficulty.     They  are  more  readily 
dissolved  in  hot  water.     Since  prolonged  hot  applications  raise  the  local  tem- 
perature  of   the    part   treated,    it  might  be  supposed  that  the  toxins  are 
rendered  more  diffusible  and  hence  may    be    gotten   rid  of   more    rapidly. 
The  chilling  of  the  tissues  would  result  in  a  greater  precipitation  of  these 
sparinglv  soluble  substances  and  so  tend  to  increase  the  pain.     It  must,  of 
course,  be  remembered  that  heat  has  a  specific  pain-relieving  action  which  is 
possibly  greater  in  importance  than  any  action  it  may  have  upon  the  local 
accumulation    of  toxins.      The  pain  of  toxic  neuralgia  may  be  relieved  by 
very  hot.  fomentations  or  the  local    electric  light   bath.     For  a    prolonged 
application,  the  hot  water  bottle  is  very  serviceable.     Any  of  these  appli- 
cations may  be  followed  by  the  heating  compress.     This  should  be  wrung 
from  tepid  or  cool  water;  rarely,  if  ever,  from  ice  water.     The  mode  and 
duration  of  the  hot  application  should  be  varied  according  to  the  character 
and  location  of  the  pain. 

In  treating  sciatica,  the  hot  fan  douche  is  a  very  effective  means.  Very 
hot  affusions  may  be  used.  Sometimes  the  hot  percussion  douche  is  more 
effectual.  It  must  always  be  borne  in  mind  that  the  cure  of  the  case 
requires  the  entire  removal  of  the  cause.  For  this  reason,  a  regime 
embodying  the  prolonged  use  of  tonic  hydrotherapy,  general  eliminative 
treatment  and  proper  diet,  is  necessary  for  the  permanent  relief  of 
neuralgias. 

2.  Inflammatory    Neuralgia.     A    very    different  plan  should  be  followed 
where  the  pain  in  nerve  trunks  is  due  to  real  inflammation.     Prolonged  cold 
applications,    even    to    almost    freezing  the  part,  give  better  results  than 
hot  applications.     For  this  purpose,  it  is  sometimes  recommended    to    use 
the  ethyl  chloride  spray.     Cold  may  also  be  applied  by  means  of  the  ice  bag, 
ice    pack    or  ice  compress.     These  should  not    be  too  thickly  covered    and 
should  be  left  in  place  a  sufficient  length  of  time  to  materially  lower  the 
temperature  of  the  part  treated.     Sometimes  derivation  by  direct  cold  and 
collateral  heat  is  very  effective.     Cold  affusions  may  be  used.     The  pain  of 
an  inflammatory  sciatica  is  often  benefited  by  the  alternate  hot  and    cold 
douche  applied  up  and  down  the  thigh-  over  the  sciatic  nerve. 


194  SEDATIVE  EFFECTS 

In  all  cases  of  neuralgia,  it  is  best  to  make  repeated  search  for  the  cause. 
While  the  majority  of  cases  of  facial  and  other  neuralgias  are  not  due  to 
conditions  which  can  be  remedied  by  operation,  yet  this  is  sometimes  the 
case.  In  this  condition,  it  might  be  mentioned  that  operation  for  facial 
neuralgia  is,  in  the  majority  of  cases,  not  only  a  failure,  but  an  actual  detri- 
ment to  the  patient.  The  relief  of  the  pain  is  merely  temporary  and, 
because  of  shock,  nerve  exhaustion,  etc.,  repeated  operations  render  the 
patient  much  more  susceptible  to  pain. 

Tenesmus — Rectal  or  Vesical 

Pain  in  hollow  muscular  organs  is  chiefly  due  to  the  contractions  of  the 
muscular  tissue.  The  activity  of  the  muscular  wall  increases  the  irritation 
arising  in  the  mucous  membrane.  To  relieve  tenesmus  of  the  bladder  or 
rectum,  we  have  found  the  hot  sitz  bath  most  effectual.  The  heat  should 
be  prolonged  a  sufficient  length  of  time  to  fully  relieve  the  pain,  Only  a 
brief  dash  of  cold  water  should  be  given  at  the  close.  In  some  cases,  it 
should  be  omitted  entirely.  Large  fomentations  or  the  hot  hip  pack  maybe 
used.  In  rectal  tenesmus,  a  small  hot  enema  or  the  starch  enema  affords 
relief.  The  enema  should  be  given  before  fomentations  or  the  hot  sitz  is 
applied.  Cold  applications  increase  the  muscular  activity,  and  hence  the 
pain. 

Dysmenorrhea 

The  condition  here  is  somewhat  similar  to  a  tenesmus.  It  is  most  fre- 
quent in  sharp  anteflexions  of  the  uterus,  or  may  be  occasioned  by  chilling. 
In  order  to  afford  immediate  relief,  it  is  necessary  to  relax  the  musculature 
of  the  organ.  Cold  causes  contraction  of  the  uterine  muscle  and  so  prevents 
the  outflow  of  blood,  while  hot  applications  relax  the  muscle.  Often  simple 
fomentations  are  sufficient  to  afford  relief.  It  may,  however,  be  neces- 
sary to  use  the  short  hot  sitz  bath.  No  cold  treatment  should  follow  it. 
The  application  of  the  unwrapped  ice  bag  to  the  sacrum  may  be  used,  accom- 
panying some  hot  application  to  the  feet  and  legs.  It  may  be  necessary  to 
continue  this  20  or  30  minutes.  Hot  applications  in  front  may  be  used  at 
the  same  time.  The  ice  bag  when  applied  anteriorally  has  the  opposite 
effect,  that  is,  it  causes  contraction  rather  than  relaxation.  Probably,  the 
explanation  of  the  action  of  the  ice  bag  to  the  sacrum  in  relaxing  the  uterus 
as  has  been  pointed  out,  lies  in  the  fact  that  the  posterior  area  is  in  less  per- 
fect reflex  relation  with  the  uterus;  and  for  this  reason,  the  reflex  is  easily 
paralyzed,  the  effect  then  being  opposite  to  that  which  we  usually  expect 
from  the  ice  bag. 

In  addition  to  these  measures,  the  hot  enema  and  very  hot  vaginal  irriga- 
tion may  be  administered  prior  to  the  use  of  the  fomentation  or  hot  sitz. 
In  the  case  of  suppressed  menses  with  pain,  when  due  to  colds  or  exposure 
to  dampness,  it  is  well  to  use  a  hot  foot  bath;  or  better,  hot  leg  bath, 
together  with  some  local  hot  applications.  This  reduces  the  extreme  pelvic 
congestion,  renders  the  outflow  easier  and  so  relieves  pain. 

Colic — Renal,  Biliary,  Intestinal 

The  pain  of  renal,  biliary  and  intestinal  colic  is  largely  due  to  spasmodic 


SPRAINS  AND  BRUISES  195 

contraction  of  the  non-striped  muscle  of  these  parts.  The  irritation  of  the 
mucous  membrane  by  the  calculus  stimulates  the  muscle  to  contract.  To 
relieve  pain  from  calculus  or  the  pain  of  intestinal  colic,  it  is  necessary  to 
use  large  hot  applications  in  order  to  secure  perfect  relaxation. 

1.  Renal  and  Biliary  Colic.      It  is  usually    considered    that    morphin  is 
absolutely  essential  in  these  conditions.      By  the  use  of  the  full  hot  blanket 
pack  or  hot  trunk  pack,  morphin    may  often  be    entirely  dispensed    with. 
If  the  pack  does  not  fully  relieve  the  pain,  a  much  smaller  dose  of  morphin 
than  would  otherwise  be  required,  will  be  sufficient.     The  blanket  should  be 
wrung  from  boiling  water,  quickly  spread  out  on  the  bed  over  a  dry  blanket 
and  as  quickly  as  possible  wrapped  about  the  patient.      It  is  not  necessary 
to  include  the  arms  in  the  pack.     A  hot  water  bottle  over  the  abdomen  and 
spine  bags  along  each  side  of  the  trunk  will  help  to  maintain  the  heat  of 
the  pack.      In  cases  where  the  pain  is  not  so  severe,  large    fomentations 
may  be  sufficient.      The  full  hot  tub  bath  gives  good  results  in  some  cases. 
Wherever  a  hot  application  is  much  prolonged,  cold  compresses  should  be 
applied  to  the  head  and  neck.     No  cold  applications  whatever  should  follow 
the  hot  pack.     Even  a  very  brief  application  of  cold  may  bring  on  the  pain. 

2.  Intestinal  Colic.      When  intestinal  colic  is  due  to  poisoning  or  simple 
diarrhea,  it  is  well  to  begin    the    treatment  by  thorough   cleansing  of  the 
intestinal  canal.      It  may  be  necessary  to  use  a  cathartic  in  order  to  com- 
pletely   remove  the  irritating    toxic    material.      In  all  cases,  hot  enemata 
should  be  given  until  the  lower  bowel  is  thoroughly  cleansed.     If  necessary, 
this  may  be  followed  by  the  starch  or  starch  and  laudanum  enema.     Following 
this,  the  most  effective  measure  for  the  relief  of  the  pain  is  the  abdominal 
fomentation.      This  should  be  continued  until  the  pain   has    been    entirely 
relieved.    The  hot  water  bottle  may  be  used  between  treatments.     Fomenta- 
tions to  the  abdomen  may  be  given  every  2  to  4  hours  or  as  frequently  as 
necessary. 

Burns 

In  the  case  of  burns  covering  a  somewhat  limited  area,  the  dressings 
usually  applied  are  sufficient  to  relieve  the  pain.  Cold  immersion  relieves 
the  pain  during  the  time  the  part  is  in  the  cold  water.  It  has,  however, 
been  our  experience  that  the  pain  is  worse  after  removal  from  the  water. 
On  the  contrary,  while  hot  immersion  is  not  very  greatful during  its  continu- 
ance, its  after  effect  is  better  than  that  of  cold  immersion.  A  neutral  or 
warm  pour  to  the  burned  part  is  very  effective  in  relieving  the  pain.  In 
extensive  burns,  it  is  often  necessary  to  use  a  full  immersion  bath  of  either 
neutral  or  cool  water.  In  the  absence  of  facilities  for  this,  a  prolonged 
wet  sheet  pack  renewed  by  frequent  sprinkling  with  cold  water  may  be  used. 
With  the  exception  of  extensive  burns  or  where  the  pain  is  unbearable,  we 
do  not  greatly  favor  the  use  of  hydrotherapy  for  the  relief  of  the  pain. 
The  use  of  picric  acid  in  saturated  aqueous  solution  followed  by  dusting'  the 
part  with  stearate  of  zinc  has  given  such  good  results  in  the  relief  of  pain, 
rapid  dermatization  and  healing  that  we  use  it  as  a  routine  treatment. 

Sprains  and  Bruises 

Hot  applications,  including  fomentations  and  hot  immersion,  are  common 


196  SEDATIVE  EFFECTS 

household  remedies  for  the  relief  of  pain  occasioned  by  sprains  and  bruises. 
These  applications  do  effectually  relieve  the  pain  and  relax  the  muscles. 
In  many  cases,  much  better  results  may  be  obtained  by  the  prolonged  cold 
immersion.  This  reduces  the  congestion  and  helps  to  prevent  excessive 
exudation  of  serum  into  the  soft  tissues  about  the  sprained  part.  Along 
this  line,  we  may  draw  a  practical  lesson  from  the  method  instinctively  pursued 
by  wild  animals.  They  usually  seek  a  stream  or  body  of  cold  water  and 
stand  in  it  for  hours  at  a  time.  Whatever  method  is  used  at  first,  after  a 
day  or  two,  it  will  be  found  advantageous  to  utilize  alternate  hot  and  cold 
applications,  such  as  the  hot  and  cold  spray,  pour  or  immersion.  These 
stimulate  the  circulation,  thus  hastening  the  absorption  of  the  edema. 

Fractures 

There  are  two  objects  to  be  attained  by  hydriatic  applications  in  fractures. 
These  are  the  relief  of  the  pain  and  the  relaxation  of  the  muscles.  The 
limb  should  be  enveloped  in  a  large  fomentation  or  immersed  in  very  hot 
water.  Care  should  be  taken  thafa  burn  or  blister  does  not  result.  These 
methods  are  in  too  common  use  to  need  extensive  discussion.  It  will  always 
be  found  easier  to  set  a  bone  if  the  muscles  have  been  thoroughly  relaxed 
by  the  preliminary  use  of  hot  applications.  The  same  principles  apply  to 
the  reduction  of  a  hernia  by  taxis. 


CHAPTER  XXII 


EXPECTORANT  EFFECTS 


There  is  a  definite  series  of  changes  accompanying  the  course  of  such  con- 
ditions as  colds,  acute  bronchitis  and  simple  croup.  In  all  congestions  and 
inflammations  of  the  mucous  membrane  of  the  respiratory  tract,  the  first 
change  is  that  of  intense  congestion  accompanied  by  swelling  and  turgescence 
of  the  membrane  which  is  dry  and  much  irritated.  In  this  condition  the 
cold  is  said  to  be  "tight"  because  of  the  extreme  irritation  and  the  fact  that 
the  dry  mucous  membrane  renders  difficult  gaseous  interchange.  Very 
soon  there  begins  to  appear  a  secretion  of  a  thick  tenacious  mucus,  accom- 
panied by  leucocytes.  Later,  the  character  of  the  secretion  becomes  altered. 
It  is  more  fluid,  contains  frothy  mucus  and  is  more  purulent  in  nature. 
When  this  change  occurs,  the  cold  is  said  to  have  "loosened."  From  this 
time  on,  expectoration  becomes  easier.  During  the  first  stage  of  the  tur- 
gescence of  the  mucous  membrane,  there  is  no  expectoration.  Later,  there 
is  a  very  small  amount  of  thick  mucus  which  is  expectorated  with  difficulty; 
and  after  the  cold  has  thoroughly  loosened,  the  quantity  is  very  much 
increased,  while  the  sputum  is  quite  fluid. 

In  the  application  of  measures  designed  to  relieve  these  conditions,  that 
which  appears  most  rational  is  the  hastening  of  this  series  of  changes  and 
relieving  such  symptoms  as  pain  and  cough.  During  the  first  stage,  that  is, 
of  congestion,  and  the  second  stage  when  there  begins  to  be  a  secretion  of 
thick  mucus,  it  is  necessary  to  decrease-the  congestion  and  increase  the  fluidity 
of  the  secretion.  This  is  best  accomplished  by  moist  heat  such  as  the  inhala- 
tion of  steam,  fomentations  to  the  chest  and  throat,  hot  water  drinking, 
the  heating  chest  pack  or  some  general  sudorific  measure.  The  moist  heat 
dilates  the  blood  vessels  and  stimulates  the  activity  of  the  mucous  glands, 
so  that  they  produce  a  more  fluid  secretion.  These  measures  should  be  con- 
tinued with  but  little  change  until  the  symptoms  are  considerably  amelior- 
ated. Then,  after  the  first  day,  it  is  best  to  employ  alternate  hot  and  cold 
applications,  the  revulsive  compress,  cold  mitten  friction,  etc.,  in  order  to 
promote  resolution,  absorb  the  exudate  and  prevent  further  excessive  secre- 
tion. This  is  best  accomplished  by  stimulating  the  circulation,  so  equalizing 
it  that  congestion  of  the  pulmonary  mucous  membrane  and  the  mucous  mem- 
brane of  the  nose  and  throat  is  decreased.  These  measures  also  stimulate 
the  depth  of  respiration  and  increase  gaseous  interchange.  All  sudorific 
measures  ease  difficult  respiration  and  increase  the  fluidity  of  expectoration. 
The  following  are  the  most  useful  measures: — 

1.  Russian  or  vapor  bath. 

2.  Inhalation  of  steam,  plain  or  medicated. 


198  EXPECTORANT  EFFECTS 

3.  Fomentations  to  chest  and  throat,  or  the  hot  trunk  pack. 

4.  Heating  chest  pack  and  heating  throat  compress. 

5.  Hot  water  drinking. 

Several  of  these  may  be  combined:  for  example,  fomentations  to  the  chest 
and  throat  may  be  accompanied  by  hot  water  drinking,  inhalation  of  steam 
and  the  hot  foot  bath.  Expectorant  effects  are  indicated  in  the  following 

conditions: — 

1.  Colds. 

2.  Acute  bronchitis. 

3.  Chronic  bronchitis. 

4.  Asthma. 

5.  Croup. 

6.  Bronchiectasis. 

7.  Pulmonary  tuberculosis. 

Precautions:  All  of  the  applications  recommended  for  expectorant  effects 
are  of  a  more  or  less  diaphoretic  nature,  and  consequently  the  patient  is 
predisposed  to  colds  and  there  is  a  greater  liability  to  return  of  the  symp- 
toms. For  these  reasons,  it  is  best  to  employ  such  measures  as  the  alcohol 
or  witch-hazel  rub  at  the  conclusion  of  the  sweating  measure,  or  some  mild 
cold  application  such  as  the  wet  hand  rub  or  cold  mitten  friction.  The  chest 
should  be  protected  by  a  dry  chest  pack.  The  clothing  should  be  sufficient 
to  provide  warmth,  and  the  patient  should  be  cautious  about  exposure  to 
drafts,  dampness,  etc. 


Colds,   Acute  Coryza,  Pulmonary  Congestion, 
Acute  Bronchitis 

In  these  conditions,  it  is  necessary  to  accomplish  the  following  results: 
First,  relieve  congestion  and  pain.  Second,  ease  the  cough  and  aid  the 
expectoration,  first  by  increasing  its  fluidity  and  latter,  the  facility  of  expec- 
toration. 

Some  general  sweating  measure  is  indicated  during  the  first  stage  of  a 
cold.  The  treatment  already  mentioned  is  indicated  at  this  time.  Fomen- 
tations to  the  chest  and  throat  should  be  repeated  at  intervals  of  3  to  5  hours 
followed  by  the  heating  compress  to  the  throat  or  chest,  according  to  the 
location  of  the  congestion.  Fomentations  also  relieve  the  excessive  cough 
and  the  pain  accompanying  the  cough.  The  drinking  of  hot  water  aids  dia- 
phoresis and  helps  to  increase  the  fluidity  of  the  secretion  by  increasing  the 
amount  of  water  in  the  blood.  From  the  beginning  of  the  cold,  the 
patient  should,  after  every  hot  treatment  be  given  a  cold  mitten  friction  or 
cold  towel  rub  and  later,  such  treatment  as  hot  and  cold  to  the  spine,  revul- 
sive compress  to  the  chest,  hot  and  cold  foot  bath,  in  order  to  equalize  the 
circulation  and  promote  return  to  the  normal  tone.  In  acute  coryza  (cold  in 
the  head)  alternate  hot  and  cold  to  the  head  may  be  used  from  the  start  and 
repeated  several  times.  A  hot  foot  bath  should  be  given  at  the  same  time.. 


CHRONIC  BRONCHITIS  199 

Croup 

In  diphtheretic  croup,  we  are  less  frequently  called  upon  to  treat  extreme 
conditions  than  before  the  introduction  of  antitoxin.  However,  in  this  dis- 
ease and  also  in  simple  and  spasmodic  croup,  expectorant  effects  are  indi- 
cated. In  the  latter  conditions  the  child  should  be  given  some  sweating 
treatment,  such  as  a  hot  foot  bath  accompanied  by  hot  moist  applications 
to  the  chest  and  neck.  This  should  be  continued  until  the  harsh,  brassy 
cough  gives  way  to  free  and  easier  expectoration.  When  this  occurs,  the 
dyspnoea  and  cyanosis  will  be  relieved.  The  inhalation  of  medicated  steam 
is  a  great  aid  in  the  treatment.  Special  inhalers  may  be  provided,  or  an 
ordinary  teakettle  or  basin  may  be  utilized  for  the  production  of  steam 
which  may  be  conveyed  to  the  patient  by  means  of  an  inhaling  funnel  or 
mask.  The  drinking  of  some  hot  liquid  will  increase  the  sweating  and 
hasten  the  loosening  of  the  secretions.  The  heating  compress  or  the  moist 
chest  pack  should  be  applied  after  the  fomentations  and  left  in  place  from 
thirty  minutes  to  two  or  three  hours.  The  child  usually  falls  into  an  easy 
sleep  following  such  treatment.  In  some  cases  it  may  be  necessary  to  dis- 
pense with  the  moist  inside  part  of  the  chest  pack,  using  only  the  dry  pack. 


Asthma 

The  treatment  of  the  asthmatic  paroxysm  by  means  of  hydrotherapy  is  a 
disappointment,  and  this  in  spite  of  the  fact  that  by  a  more  or  less  prolonged 
course  of  hydriatic,  dietetic  and  climatic  treatment,  very  severe  cases  of 
asthma  of  long  standing  are  almost  completely  cured.  .  Permanent  and  very 
decided  results  are  obtained  in  cases  that  submit  to  treatment  for  a  suffi- 
cient length  of  time.  Hydriatic  applications,  however,  may  be  made  to 
assist  in  relieving  the  patient  during  the  paroxysm.  Two  objects  are  to  be 
attained, — the  lessening  of  the  dyspnoea  and  facilitating  expectoration. 
These  may  be  accomplished  by  some  mild  sweating  treatment,  fomentations 
to  the  chest,  or  the  inhaling  of  medicated  steam.  As  soon  as  the  patient 
breaks  out  into  a  gentle  perspiration,  the  dyspnoea  begins  to  lessen. 


Chronic  Bronchitis 

This  condition  is  treated  in  much  the  same  manner  as  any  chronic  inflam- 
mation. The  results  to  be  obtained  are, — first,  relief  of  the  cough;  and 
second,  lessening  of  the  amount  of  expectoration  and  facilitating  its  expul- 
sion. The  patient  should  be  given  a  definite  program  of  treatment  such, 
for  example,  as  the  following:  Hot  foot  bath,  together  with  fomentations 
to  the  chest  and  the  cold  mitten  friction;  also  fomentations  or  revulsive 
compress  to  the  abdomen,  revulsive  compress  to  the  chest,  hot  and  cold  to 
the  spine,  cold  towel  rub,  salt  glow.  It  is  usually  best  to  have  the  patient 
wear  some  form  of  a  dry  chest  pack.  All  of  these  measures  stimulate  the 


200  EXPECTORANT  EFFECTS 

circulation,  reducing  the  venous  stasis  in  the  lungs,  and  promote  resolution. 
The  fact  that  the  circulation  in  the  lungs  is  more  rapid  tends  to  decrease 
the  amount  of  the  secretion.  The  patient's  general  vital  resistance  is  raised 
by  such  a  course  of  treatment. 

The  digestion  requires  special  attention.  "Stomach. cough"  is  not  a  bad 
name  for  many  cases  of  chronic  bronchitis,  since  the  indigestion,  auto-intoxi- 
cation and  sluggish  condition  of  the  liver  are  very  largely  accountable  for 
the  excessive  secretions.  If  the  patient  may  be  induced  to  give  up  all  com- 
plicated dishes,  desserts,  meats,  rich  and  highly  seasoned  foods,  and  limit  him- 
self to  a  very  simple  diet,  the  condition  will  yield  to  treatment  much  more 
readily.  The  same  is  true  of  bronchial  asthma.  So  astonishing  are  the  results 
obtained  in  both  these  diseases  by  rigid  dietetic  regulation,  accompanied  by 
general  tonic  treatment  that,  although  requiring  a  long  time  to  produce, 
they  seem  almost  miraculous. 


CHAPTER    XXIII 


DIAPHORETIC  EFFECTS 


There  are  a  large  variety  of  measures  which  induce  general  perspiration. 
Any  hot  application,  even  if  local,  may  induce  perspiration  over  the  entire 
body.  The  measures  to  be  selected  as  most  efficient  in  treating  a  disease 
depend  upon  the  causes  of  and  conditions  in  that  disease. 

The  following  is  a  list  of  the  principal  diaphoretic  measures: — 

1.  Electric  light  bath  (general  or  local) . 

2.  Sun  bath. 

3.  Turkish  bath. 

4.  Superheated  air  bath  (250°  to  400°  F.). 

5.  Russian  bath  or  vapor  bath. 

6.  Full  hot  bath. 

7.  Hot  blanket  pack. 

8.  Dry  pack. 

9.  Electro-thermal  pack. 

10.  Heating  wet  sheet  pack. 

11.  Hot  spray  or  douche. 

12.  Hot  leg  or  foot  bath. 

13.  Hot  sitz-bath. 

14.  Fomentations  to  the  spine. 

15.  Hot  water  drinking. 

16.  Hot  enema. 

Each  measure  has  its  own  range  of  applicability  and  special  adaptability 
to  the  needs  of  the  individual  case.  The  more  local  and  milder  measures 
have  a  wide  range  of  usefulness.  The  more  extreme  and  general  heating 
treatments  have  certain  counterindications  which  must  not  de  disregarded. 
Tonic  cold  applications  should  usually  follow  sweating  treatment.  The  main 
effects  of  diaphoretic  applications  are  as  follows: — 

1.  Increase  perspiration  (water  chiefly). 

2.  Increase  catabolic  changes  (spoliative  or  reducing). 

3.  Increase  elimination  of  toxins  through  the  skin  and  through  the  kid- 
neys indirectly  by  relieving  these  organs  when    overworked  or  congested, 
thus  making  more  efficient  the  work  which  is  done.     In  health,  diaphoretic 
measures  do  not  increase  the  amount  of  urine  and  may  considerably  decrease 
it,  but  in  all  conditions  where  there  is  lessened  functional  activity  of  the 
kidneys,  diaphoretic  measures  tend  to  produce  diuresis  and  hasten  the  elimi- 
nation of  toxins  through  that  channel. 

4.  Increase  the  activity  of  the  sebaceous  glands  and  skin  in  general,  thus 
improving  its  nutrition. 


202  DIAPHORETIC  EFFECTS 

5.  Relieve  internal  congestion. 

6.  Decrease  dropsical  effusions. 

7.  Prepare  the  patient  for  cold  treatment  by  promoting  ability  to  react. 

There  are  a  large  number  of  conditions  in  which  diaphoretic  measures  are 
indicated.  In  a  few  diseases  the  most  vigorous  sweating  treatments  may 
be  used  with  great  benefit.  Below  is  given  a  list  of  diseases  and  morbid 
conditions  which  require  special  diaphoretic  treatment.  Very  vigorous  means 
may  de  used  in  all  but  the  first  three. 

Indications  for  diaphoresis. 

1.  Icterus. 

2.  Systemic  poisoning  (toxemia). 

3.  Internal  congestions. 

4.  Obesity. 

5.  Acute  rheumatic  fever. 

6.  Chronic  articular  rheumatism. 

7.  Gout. 

8.  Bright's  disease,  acute  and  chronic. 

9.  Uremia. 
10.  Eclampsia. 

It  will  be  noticed  that  nearly  all  of  these  diseases  are  intimately  associated 
with,  or  due  to,  defective  metabolism.  The  treatments  that  promote  dia- 
phoresis and  diuresis  all  powerfully  affect  metabolism.  Internal  tissue 
changes  are  of  course  the  antecedents  of,  and  are  manifest  by,  changes  in 
excretion.  It  is  these  tissue  changes  and  the  consequent  elimination  of  car- 
bon dioxide  and  nitrogenous  wastes  that  are  of  so  much  importance.  For 
this  reason  the  majority  of  the  diseases  considered  under  the  two  heads  of 
diaphoretic  and  diuretic  effects  might  with  equal  or  greater  consistency  be 
considered  under  the  single  head  of  metabolic  effects.  We  have,  however, 
thought  best  to  consider  most  of  these  in  the  following  chapter  after  a  general 
statement  of  the  means  of  producing  diuretic  effects  and  the  principles  involved 
in  such  effects. 

Counterindications  to  extreme  sudorific  measures. 

1.  Asthma. 

2.  Organic  heart  disease. 

3.  Emaciated  rheumatics  and  diabetics. 

4.  Sunstroke  and  heatstroke. 

5.  Pulmonary  tuberculosis. 

6.  Asthenic  fevers. 

7.  Icterus. 

8.  Emaciation  and  exhaustion. 

9.  Old  age. 

Obesity 

In  considering  the  effects  of  thermic  applications  upon  tissue  changes  in 
respect  to  both  nitrogenous  and  carbonaceous  metabolism,  it  was  shown 
that  all  forms  of  cold  treatment  increase  catabolic  changes,  also  that  exces- 
sive heat  or  long  continued  heat  has  the  same  effect.  The  two  extremes, 


OBESITY  203 

however,  do  not  have  the  same  effect  upon  anabolism,  heat  having  little  or 
no  tendency  to  increase  the  building  up  processes  through  increased  absorp- 
tion and  assimilation  of  food.  Tonic  cold  applications  often  increase  ana- 
bolism more  than  catabolism.  It  is  for  this  reason  that  cold  applications 
signally  fail  in  securing  any  great  reduction  in  weight.  The  patient  may 
lose  a  few  pounds. 

Of  course,  the  general  vitality  of  the  patient  and  all  nutritive  processes 
are  enhanced  by  alternating  hot  and  cold  applications.  This  is  doubtless 
the  more  rational  way  to  treat  obesity,  since  it  is  more  necessary  to  improve 
the  general  condition  of  the  patient  than  to  reduce  the  weight;  but  if  the 
reduction  of  the  weight  is  the  objective  point,  it  is  necessary  to  resort  to 
extreme  sudorific  measures,  unaccompanied  by  cold  applications.  For  this 
reason,  it  is  not  possible  to  greatly  reduce  the  weight  of  persons  suffering 
from  fatty  heart,  accompanying  the  general  obesity.  Spoliative  and  reduc- 
ing measures  aim  at  increasing  catabolism  without  a  corresponding  increase 
in  anabolism.  All  extreme  sudorific  measures  available  should  be  used  in 
this  condition.  Those  which  will  be  found  most  helpful  are  the  Russian 
bath,  Turkish  bath,  electric  light  bath,  full  blanket  pack,  electro-thermal 
pack  and  sweating  wet  sheet  pack.  The  full  hot  bath  and  the  mud  baths, 
commonly  used  at  hot  springs,  may  be  used.  These  do  not,  however,  have 
any  advantage  over  the  first  three  measures  mentioned. 

The  patient  should  have  one  prolonged  sweating  treatment  daily.  It  is 
often  necessary  to  finish  with  a  very  short  cold  spray.  This  should  not  be 
greatly  prolonged  for  the  reasons  above  mentioned.  The  patient  should 
take  as  much  vigorous  exercise  as  possible.  Heavy  massage  may  also  be 
used.  It  is  needless  to  say  that  the  following  of  such  a  program  will  result 
in  weakening  the  patient  as  well  as  in  reducing  the  weight.  These  measures 
may  all  fail  unless  the  diet  is  reduced,  especially  as  regard  the  total  number 
of  calories.  As  soon  as  the  patient  returns  to  his  usual  habits  of  inactivity 
and  overfeeding,  there  will  be  a  prompt  gain  in  weight  which  will  replace  all 
that  has  been  lost.  Extreme  sweating  treatments  do,  however,  materially 
reduce  the  weight  and,  by  guarding  the  diet  and  encouraging  exercise,  the 
loss  in  weight  may  be  quite  permanent. 


It  is  usually  impossible  to  employ  prolonged  or  extreme  diaphoretic  treat- 
ment in  this  condition,  but  free  perspiration  should  be  encouraged,  since 
by  increasing  the  elimination  of  bile  through  the  sweat,  it  relieves  the  nerv- 
ous irritability  and  aids  in  relieving  pruritus.  Local  hot  applications  are 
illy  borne  because  of  the  extreme  sensitiveness  of  the  skin.  The  electric 
light  bath  is  a  very  efficient  means,  since  its  heat  is  evenly  distributed. 


Systemic    Poisoning 

In  many  conditions  in  which  toxic  substances  circulate  in  the  blood  and 
lymph,  free  diaphoresis    materially    hastens  their  elimination.      Such  sub- 


204  DIAPHORETIC  EFFECTS 

stances  may  be  produced  by  auto-intoxication  from  intestinal  sources,  or 
faulty  metabolism.  General  poisoning  may  result  from  the  ingestion  of 
ptomaines,  lead,  mercury,  alcohol,  etc.  In  some  cases,  vigorous  diaphoresis  is 
necessary;  in  others,  only  mild  diaphoresis  with  copious  water  drinking 
should  be  used.  Because  of  the  weakness  and  debility  resulting  from  the 
poison,  extreme  sweating  measures  can  not  be  used.  A  short  electric  light 
bath  is  often  all  that  is  necessary. 


Internal  Congestions 

The  use  of  sudorific  measures  in  relieving  congestion  of  the  viscera  has 
been  considered  elsewhere,  especially  in  connection  with  inflammations  and 
diseases  of  the  kidneys.  It  is  not  possible  for  an  extreme  congestion  to 
exist  in  the  internal  organs  while  the  skin  is  red  and  congested  as  occurs  in 
a  sweating  treatment.  But  in  order  to  more  permanently  relieve  the  internal 
congestion,  it  is  necessary  that  the  blood  be  retained  in  the  skin.  This  is 
not  accomplished  by  the  hot  alone,  but  can  be  by  the  reaction  hyperemia 
resulting  from  a  cold  friction.  The  principle  of  these  effects  has  been  con- 
sidered in  connection  with  the  subjects  of  derivation  and  fluxion.  The 
relief  of  visceral  congestions  by  general  sudorific  measures  is  indicated  in 
acute  nephritis,  eclampsia,  uremia,  pulmonary  congestion,  acute  pleurisy 
and  the  early  stages  of  many  infectious  diseases  such  as  influenza,  measles, 
scarlet  fever,  etc. 


CHAPTER    XXIV 
DIURETIC  EFFECTS 


We  have  previously  shown  the  close  connection  existing  between  the  func- 
tions of  the  kidneys  and  skin  in  diseases  of  either  of  these  organs.  In  the 
preceeding  chapter  a  list  of  the  various  sudorific  measures  is  given.  All  of 
these  treatments  are  beneficial  in  conditions  of  defective  kidney  activity. 
It  has  long  been  known  that  nephritis  and  diseases  of  metabolism,  closely 
associated  with  the  functions  of  the  kidney,  are  benefited  by  free  diapho- 
resis. In  these  diseases  all  brisk  sudorific  measures  indirectly  increase  uri- 
nary secretion.  This  is  probably  due  to  the  fact  that  renal  congestion  is 
lessened,  the  stagnation  relieved,  so  that  while  there  is  less  blood  in  the 
kidneys  at  any  one  time,  the  rapidity  of  the  renal  circulation  is  increased. 
The  secretion  of  urine  is  therefore  more  efficient  and  the  quantity  of  the 
watery  and  solid  constituents  is  increased.  The  increase  in  urinary  solids  is 
due  not  alone  to  stimulation  of  the  renal  epithelium  by  a  quickened  circula- 
tion, but  also  to  heightened  metabolic  changes  occurring  in  the  tissues  them- 
selves. The  stimulation  of  the  general  circulation  and  especially  of  the 
hepatic  circulation  and  of  the  liver  cells  produced  by  sweating  treatment  or 
accompanying  the  reaction  to  cold  treatment,  has  been  shown  to  increase  the 
toxicolytic  powers  of  the  liver.  Toxemia  is  thus  lessened  in  a  very  direct 
manner.  The  blood  being  less  toxic,  irritation  of  the  renal  cells  is  decreased 
and  the  work  done  by  the  kidney  is  more  efficient. 

The  following  are  the  principle  diuretic  measures  which  are  useful  in  kid- 
ney insufficiency  and  allied  conditions:— 

1.  Full  hot  blanket  pack. 

2.  Electric  light  bath. 

3.  Russian  and  other  vapor  baths. 

4.  Hot  air  baths. 

5.  Full  warm  tub  bath. 

6.  Water  drinking  (especially  with  above). 

7.  Cold  (or  hot  and  cold)  douche  to  lower   sternum   and   lumbar   spine 
(entire  width  of  back). 

8.  Cold  heating  trunk  pack  or  the  rubbing  wet  sheet  pack. 

9.  Fomentations  to  lumbar  spine. 
Indications. 

1.  Bright's  disease,  acute  or  chronic. 

2.  Uremia,  eclampsia  and  other  toxemias. 

3.  Acute  suppression  of  the  urine. 

4.  Ether  and  post-operative  nephritis. 

5.  Ptomaine  poisoning. 

6.  Poisoning  by  lead,  turpentine,  alcohol,  etc. 


206  DIURETIC  EFFECTS 

Gout  and  Chronic  Rheumatism 

General    Consideration 

The  literature  on  the  purin  diathesis  is  most  voluminous  and  much  of  it 
unreliable;  there  are,  however,  some  important  facts  regarding  purin  metab- 
olism that  have  been  sufficiently  well  proven  to  allow  of  their  being  used  as 
a  foundation  for  the  basic  principles  involved  in  the  treatment  of  these  con- 
ditions. We  can  not  here  attempt  anything  like  a  complete  consideration 
of  this  question,  but  merely  point  out  those  facts  which  seem  to  us  to  be  of 
importance  in  determining  the  treatment.  There  seem  to  be  three  causes 
for  the  accumulation  of  basic  purins  and  uric  acid  in  the  system.  These 
are, — first,  excessive  ingestion  of  purin-containing  foods  over  long  periods 
of  time;  second,  defective  and  deficient  xanthin  oxidation  and  uricolysis;  and 
third,  decreased  elimination  of  purins  because  of  kidney  insufficiency. 

To  provide  a  diet  free  from  purin  is  not  difficult  and  so  the  removal  of  this 
first  cause  is  a  comparatively  easy  matter.  To  remedy  the  second  is,  how- 
ever, a  more  difficult  matter.  It  has  been  shown  how  applications  of  both 
heat  and  cold  accomplish  a  quite  thorough  xanthin  oxidation,  i.  e.,  a  change 
of  the  basic  purins  to  uric  acid.  This  change  of  basic  purins  to  uric  acid  is 
a  distinct  advantage,  as  uric  acid  is  less  irritating  to  the  renal  epithelium 
than  the  bases.  "Mammals  form  uric  acid  only  from  the  purins  and  have 
the  power  of  destroying  some  of  the  uric  acid  formed.  This  uricolytic  power 
is  relatively  weak  in  man."1 

Nucleoproteids  are  converted  into  free  purins  and  these,  in  turn,  are 
changed  into  uric  acid  by  the  loss  of  nitrogen  and  the  addition  of  oxygen. 
"Wiechowski  has  particularly  studied  the  enzyme  concerned  in  the  destruc- 
tion of  uric  acid  by  the  tissues,  and  the  fate  of  free  uric  acid  in  the  body. 
This  uricolytic  enzyme,  which  has  been  appropriately  called  uricase  by 
Batteli  and  Stern,  is  an  oxidizing  enzyme,  acting  best  in  experimental  diges- 
tions when  a  lively  current  of  air  is  running  through  the  digestion  mixture, 
and  which  seems  not  to  be  present  in  the  blood  plasma  and  tissue  fluids,  but 
only  in  the  cells.  It  acts  rapidly  and  with  striking  effect,  for  active  organ 
extracts  are  sometimes  able  to  destroy  quite  considerable  quantities  of  uric 
acid  in  a  few  hours;  for  example,  one  gram  of  powdered  tissue,  dry  weight, 
can  often  destroy  totally  0.1  gram  of  uric  acid  in  four  hours.  Unlike  the 
enzymes  of  autolytic  disintegration  of  tissues,  uricase  is  not  inhibited  by  the 
presence  of  an  excess  of  serum.  Another  interesting  feature  is  that  this 
enzyme  acts  reversibly,  or  at  least  tissue  extracts  which  destroy  uric  acid 
with  a  current  of  air  running  through,  soon  build  up  the  uric  acid  again 
u'li en  the  air  is  shut  off."2 

The  above  facts  show  the  benefit  to  be  derived  from  hydrotherapy  in 
stimulating  the  circulation,  increasing  the  oxygen-carrying  capacity  of  the 
red  cells  and  increasing  oxidation  in  the  body  tissues.  Out-of-door  life  in 

1  H.  G.  Wells— Trans.  Chicago  Pathological  Society,  May  1,  1909. 

2  Editorial  in  Journal  of  American  Medical  Association,  October  9,  1909,  p.  1191;  see  also  The 
Oxidases,  Bulletin  No.  59,  p.  103,  of  Hygienic  Laboratory,  Public  Health  and  Marine  Hospital 

Service  of  the  United  States. 


RHEUMATISM  AND  GOUT  207 

the  fresh  air  and  sleeping  out  of  doors  furnishes  the  abundant  supply  of  oxy- 
gen so  necessary  to  uricolysis. 

In  addition  to  the  effects  of  hydrotherapy  certain  articles  of  diet  play  an 
important  part  in  the  prevention  of  uricacidemia.  This  is  notably  so  of 
fruit.  "Weis,  in  1898,  asserted  that  after  eating  fruit  the  uric  acid  of  the 
urine  is  decreased  and  the  hippuric  acid  increased."3  "Wohler  found  uric 
acid,  but  no  hippuric  acid,  in  the  urine  of  sucking  calves,  so  long  as  they 
consumed  nothing  but  milk.  But  as  soon  as  they  passed  on  to  vegetable 
food,  the  uric  acid  disappeared  and  hippuric  acid  was  substituted.  It  thus 
appears  that  the  benzoic  acid  arising  from  vegetable  diet  siezes  upon  the 
glycocol  and  prevents  the  synthesis  of  uric  acid. 

It  is  useless  merely  to  give  benzoate  of  sodium,  as  I  have  proved  by  many 
experiments.  But  here  again  it  should  not  be  forgotten  that  it  is  not  in  our 
power  to  make  the  benzoic  acid  reach  the  proper  point  at  the  proper  moment 
when  the  glycocol,  before  its  union  with  the  cyanic  acid  could  reach  it.  As 
already  mentioned,  the  benzoic  acid  in  vegetable  food  is  not  generally 
contained  as  such,  but  is  formed  in  the  body  by  the  decomposition  and  oxi- 
dation of  more  complex  combinations.  It  is  quite  possible  that  these  latter 
are  taken  up  by  the  cells  in  which  glycocol  occurs,  while  the  benzoic  acid 
already  formed  is  rejected."4 

The  use  of  medicinal  substances  in  the  treatment  of  gout,  outside  of  those 
found  in  man's  natural  diet  is  a  disappointment.  This  is  true  of  benzoic  acid, 
the  salicylates  and  also  of  lithium.  This  latter  neither  affects  the  solubility 
of  uric  acid  in  the  tissues  nor  in  the  slightest  increases  its  elimination  by 
the  kidneys. 

Even  if  lithium  exerted  an  influence  on  the  solubility  of  uric  acid,  the 
amounts  present  in  commercial  lithia  waters  would  be  too  minute  to  accom- 
plish anything.  Relative  to  this  fact,  Dr.  Henry  Leffmann  says,  —  5 

"On  the  result  of  an  analysis  of  about  two  score  of  the  so-called  mineral 
waters,  the  Bureau  of  Chemistry  of  the  Department  of  Agriculture  has 
recently  issued  a  circular  of  inquiry  the  essential  features  of  which  I  give 
herewith.  It  has  been  found  that  nearly  all  "lithia  waters"  either  contain 
only  spectroscopic  traces  of  lithium  (unweighable  quantities  in  from  2  to  4 
liters),  or  contain  less  than  one  part  per  million  (approximately  0.05  grain 
per  gallon)  of  lithium." 

Along  the  same  line  we  quote  the  following  from  Bunge,  — (i 

"If  it  be  desired  to  prevent  the  formation  of  uric  acid  sediments,  or  to 
dissolve  concretions  that  are  already  formed,  by  the  administration  of  alka- 
lies, it  is  more  sensible  to  advise  the  use  of  fruits  and  potatoes  than  to  order 
alkaline  mineral  waters,  the  contined  use  of  which  may  produce  disturbances 
which  we  are  unable  to  estimate.  Because  the  combination  of  uric  acid 
and  lithia  is  more  soluble  in  water  than  its  combination  with  soda  or  potash, 
it  has  been  thought  necessary  to  treat  the  uric  acid  diathesis  with  a  few 


Journal  of  American  Medical  Association  of  February  19,  1910. 
6    Physiological  and  Pathological  Chemistry,  Second  English  Edition,  pp.  322 


208  DIURETIC  EFFECTS 

decigrammes  of  carbonate  of  lithia,  or  even  with  mineral  waters  containing 
one  centigram  of  lithia  to  the  liter.  This  naive  idea  simply  implies  ignor- 
ance of  Berthollet's  law.  We  know  that  in  solutions  of  bases  and  acids, 
every  acid  is  distributed  to  all  the  bases  in  proportion  to  their  quantity.  It 
follows  that  only  the  very  smallest  portion  of  uric  acid  will  combine  with 
the  lithia,  the  largest  proportion  combining  with  the  preponderating  quan- 
tity of  soda,  which  we  introduce  as  chloride  of  sodium.  The  largest  propor- 
tion of  lithia  will  reappear  in  the  urine,  united  with  the  chlorine  of  the  chlor- 
ide, with  sulphuric  and  phosphoric  acid.  There  will  be  no  increase  in  the 
solubility  of  uric  acid." 

Treatment 

Chronic  rheumatism,  gout  and  allied  conditions,  such  as  the  myalgias, 
lumbago,  etc.,  are  usually  treated  by  diaphoretic  measures.  It  must  be  con- 
fessed, however,  that  the  majority  of  rheumatics  are  not  able  to  stand  such 
treatment.  Only  those  who  are  obese  or  of  more  than  average  weight  can 
stand  extreme  sweating  measures.  It  is  for  these  reasons  that  many  a  rheu- 
matic patient  leaves  a  course  of  baths  at  the  hot  springs  in  worse  condition 
than  when  he  began.  Many  and  many  are  the  patients  that  year  after  year 
visit  the  various  spas  of  this  country  and  Europe,  deriving  each  time  only  a 
temporary  benefit.  For  this,  there  are  two  reasons.  All  are  given  the  same 
routine  of  hot  baths,  regardless  of  the  individual  conditions  and  needs. 
Obese  or  emancipated,  they  are  all  treated  alike.  Second,  there  is  a  failure 
to  eliminate  from  the  diet  all  purin-containing  foods  and  reduce  to  a  mini- 
mum the  proteid  intake.  Chittenden  has  shown  that  a  daily  ration  contain- 
ing 35  to  60  grams  of  proteid  is  not  only  compatible  with  perfect  health, 
but  also  conducive  to  gain  in  muscular  capacity,  increasing  the  endurance  to 
prolonged  muscular  effort  and  lessening  fatigue.  In  chronic  rheumatism 
and  gout,  the  proteid  should  be  reduced  to  the  least  amount  compatible  with 
the  actual  need  of  the  body  for  nitrogen.  As  pointed  out  by  Garrod  every 
particle  of  food  not  absolutely  needed  for  the  nourishment  of  the  body 
merely  nourishes  the  disease.  One  can  not  hope  to  cure  disease  unless  the 
cause  is  removed.  In  rheumatism,  the  two  chief  causes  are  overfeeding 
and  under  exercise.  The  overfeeding  is  in  the  line  of  heavily  proteid  foods 
and  foods  containing  purin.  These  must  be  eliminated  from  the  diet  if  great 
benefit  is  to  be  derived  from  treatment. 

For  practical  purposes,  we  must  divide  chronic  rheumatism  into  two  classes, 
viz.,  obese  rheumatics  and  emancipated,  anemic  rheumatics.  In  the  first 
class,  sweating  treatment  may  be  used  with  benefit  when  properly  combined 
with  tonic  measures.  In  the  second  class,  extreme  sweating  treatment  is 
not  permissible. 

Rheumatism  with  Obesity.  Those  patients  who  are  well  nourished  may 
be  given  a  thorough  sweating  treatment  daily.  Any  of  the  sudorific  meas- 
ures recommended  in  obesity  are  serviceable.  The  Turkish  bath,  Russian 
bath,  electric  light  bath,  hot  blanket  pack,  sweating  wet  sheet  pack,  or  elec- 
tro-thermal pack  are  all  applicable.  Their  effects  may  be  greatly  enhanced 
by  free  water  drinking.  The  mineral  waters  possess  no  advantage  over  any 
pure  water.  The  beneficial  results  are  derived  from  the  free  perspiration 
and  diuresis  it  induces.  It  thus  affords  ample  solvent  for  the  increased 


GOUT  AND  RHEUMATISM  209 

nitrogen  excretion.  F.  Umber 7  claims  that  alkaline  water  has  the  opposite 
effect;  also  that  the  blood  of  gouty  patients  is  able  to  dissolve  larger  propor- 
tions of  free  uric  acid  than  it  ever  contains.  He  declares  that  none  of  the 
alkalies  or  mineral  waters  have  any  specific  influence  on  the  purin  metabol- 
ism in  gout  and  that  the  propaganda  for  the  "lithium  content,"  etc.,  of 
springs  should  be  abandoned. 

Tonic  measures  should  not  be  neglected.  The  strength  should  be  main- 
tained and  the  circulation  stimulated.  All  hot  baths  should  be  followed 
by  some  form  of  cold  treatment.  These  may  at  first  have  to  be  mild,  but 
obese  patients  stand  cold  treatment  well.  The  alternate  hot  and  cold  per- 
cussion douche  is  an  excellent  means.  It  serves  as  a  massage,  stimulates 
the  vasomotors,  and  restores  the  tone  lost  because  of  the  hot  bath.  It  should 
be  applied  especially  to  the  spine  and  legs  and  should  consist  of  from  three 
to  five  complete  changes  from  hot  to  cold.  The  patient  should  be  dried  from 
the  cold  and  may  either  rest  or  take  exercise  after  it,  according  to  the  con- 
ditions of  the  particular  case  under  observation.  Individualization  is  the 
life  of  therapy  no  less  with  rheumatism  than  with  other  diseases.  Light  or 
heavy  massage  may  be  given.  The  massage  douche  is  highly  recommended 
by  some.  It  possibly  possesses  some  advantage  over  the  percussion  douche. 
Other  tonic  applications  may  be  used,  such  as  cold  affusions  and  general 
sprays  and  showers.  Later  in  the  disease,  the  wet  sheet  rub  may  be  used 
to  advantage. 

Rheumatism  with  Emaciation.  This  condition  is  doubtless  in  some  cases 
the  direct  result  of  "hot  springs"  treatment.  Hot  treatment  must  be  used 
with  much  caution.  The  vigorous  sweating  treatments  are  never  to  be 
employed  if  the  patient  is  under  weight.  Local  hot  applications  are  permis- 
sible and  a  mild  sweating  treatment  once  a  week  may  in  some  cases  be  ven- 
tured upon.  Hot  applications  to  the  swollen  joints,  such  as  fomentations, 
local  hot  air  baths,  superheated  air,  or  local  electric  light  bath  should  be 
followed  by  a  tonic  friction.  At  first,  this  may  be  a  wet  hand  rub  with 
tepid  water,  then  with  cold  water  and  later,  the  cold  mitten  friction.  These 
frictions  should  be  applied  to  the  muscular  portions  of  the  body,  the  swollen 
joints  being  avoided.  The  joints  should  be  enveloped  in  heating  compresses 
or  packs  wrung  from  cold  water.  These  should  be  thoroughly  covered  with 
several  layers  of  flannel  or  absorbent  cotton,  if  necessary,  in  order  to  exclude 
the  air.  The  effect  may  be  increased  by  counterirritants  or  anodynes.  After 
a  time  the  alternate  soft  spray  douche  may  be  applied  to  the  joints  and  the 
body  generally.  When  convalescence  is  well  established,  the  patient  should 
be  given  daily  some  general  tonic  treatment  with  only  short  preliminary  hot 
applications. 

In  real  gout,  i.  e.,  where  the  disease  is  localized  in  the  metatarso-phalan- 
geal  joint  of  the  great  toe,  the  tonic  measures  outlined  for  chronic  rheuma- 
tism must  be  used  in  the  interval.  Only  hot  applications  can  be  made  to 
the  foot  during  the  paroxysm. 

At  first,  the  patient  suffering  from  rheumatism  will  complain  some  of 
increased  stiffness  and  possibly  pain  in  the  joints  after  even  a  mild  cold  fric- 
tion. This  should  not  deter  the  physician  from  following  the  plan  outlined 

7    Therapie  der  Gegenwart,  February,  L,  No.  2.,  pp.  73  to  120. 


210  DIURETIC  EFFECTS 

nor  cause  discouragement  on  the  part  of  the  patient.  If  much  complaint  is 
made,  the  alcohol  rub  may  for  a  time  be  substituted. 

Faradization  of  the  joints  by  the  rapid  faradic  current  helps  to  relieve 
the  pain  and  the  annoying  parassthesias  that  keep  the  patient  awake. 
Gentle  massage  of  the  muscles  and  rubbing  to  the  spine  are  helps  in  treat- 
ing the  insomnia.  The  myalgias  such  as  lumbago  may  be  treated  much  as  obese 
rheumatics.  In  lumbago,  however,  the  most  vigorous  hot  and  cold  percussion 
douche  to  the  back  should  be  used,  followed  by  heavy  massage  or  firm,  deep 
vibration  to  the  large  muscles  of  the  back.  These  relieve  the  pain  as  milder 
measures  will  not. 

In  some  cases  of  rheumatism,  notably  where  the  patient  is  bed-ridden  or 
must  be  closely  confined  to  the  wheel  chair,  it  is  best  to  follow  a  somewhat 
different  plan  than  that  outlined  above.  In  these  cases,  only  mildly  hot 
local  applications  such  as  the  fomentation,  radiant  heat  and  the  hot  foot 
bath  should  be  used.  The  usual  regime  of  cold  treatment  should  be  omitted 
and  its  place  taken  by  carefully  applied  but  thorough  massage.  This  mas- 
sage should  include  special  attention  to  nerve  stimulation,  spinal  and  abdomi- 
nal movements.  The  use  of  faradic  and  sinusoidal  electricity  for  the  same 
purpose  is  an  addition  of  distinct  advantage. 

In  all  cases  of  chronic  rheumatism,  special  attention  must  be  given  to  the 
alimentary  tract  and  to  the  digestion.  Modern  investigations  into  the  con- 
tributing causes  of  chronic  articular  rheumatism  are  turning  more  and  more 
to  alimentary  stasis,  intestinal  infections  and  autointoxications  for  an  explan- 
ation of  the  pathogenesis  of  gouty  rheumatism.  The  routine  use  of  gastric 
lavage  and  copious  enemata  for  a  limited  time  may  be  productive  of  excel- 
lent results.  These  treatments  must  be  thorough  to  be  effective.  Purin 
accumulation  through  defective  xanthin  oxidation  and  very  limited  urico- 
lysis  are  a  part  of  this  autointoxication,  and  are  surely  to  be  traced  to  an 
overworked  and  functionally  deranged  liver  as  one  source  of  their  occur- 
rence. 

Bright's  Disease 

Diaphoretic  measures  are  valuable  in  both  acute  nephritis  and  in 
the  various  clinical  and  pathological  varieties  of  chronic  nephritis.  It  is 
hardly  necessary  for  our  purpose  to  discuss  the  structural  alterations  occur- 
ring in  the  kidneys  in  Bright's  disease.  Only  in  acute  nephritis  is  there 
hope  of  any  marked  restoration  of  the  normal  stucture.  However,  the 
functional  perversions  may  to  a  great  extent,  be  corrected.  The  alteration 
of  function  which  is  the  chief,  if  not  the  sole  cause  of  the  various  clinical 
manifestations  of  nephritis,  is  the  renal  impermeability  and  insufficiency  in 
the  elimination  of  nitrogenous  wastes  and  salines.  There  is  also  an  abnor- 
mal permeability  to  albumen  and,  in  some  cases,  to  water,  notably  so  in  the 
interstitial  variety  of  chronic  nephritis. 

In  interstitial  nephritis  and  the  kidney  of  arterio-sclerosis,  the  high  blood 
pressure  is  a  prominent  symptom  and  is  due,  at  least  to  a  great  extent,  to 
nitrogenous  toxins.  "Experiments  on  patients  with  chronic  nephritis  have 
shown  that  rich  protein  diet  increases  tension  and  disturbs  the  general  con- 


BRIGHTS  DISEASE  211 

dition  of  the  patient  for  the  worse.  Muller  describes  an  individual  in  whom 
a  change  from  milk  and  carbohydrate  diet  to  rich  meat  diet  caused  pressure 
to  rise  from  140  to  190.  Rich  meat  diet  causes,  in  nephritics,  headache,  one 
of  the  earliest  and  most  constant  symptoms  of  uremia,  and  one  which  has  a 
definite  relation  to  hypertension."8 

Treatment  may,  therefore,  be  directed  toward  the  attaining  of  two 
objects:  First,  decreasing  the  amount  of  toxic  substances  and  salines  the 
kidneys  are  required  to  excrete.  Second,  increasing  renal  sufficiency,  so 
shaping  conditions  that  increased  elimination  may  occur  without  increased 
strain  and  irritation  of  the  kidneys.  In'  order  to  meet  the  first  indication, 
it  is  necessary  to  bring  about  several  changes.  The  ingestion  of  purins 
(exogenous)  must  be  stopped.  The  consumption  of  proteids  must  be  limited 
as  far  as  the  'needs  of  the  system  will  allow.  By  general  hygiene,  exercise, 
etc.,  one  may  decrease  the  formation  of  intestinal  toxins  and  promote  com- 
plete oxidation  of  nitrogenous  wastes.  These  results  may  be  attained  by 
regulation  of  the  diet  and  attention  to  digestion.  For  a  time  it  is  well  also 
to  limit  the  use  of  salt  to  what  naturally  occurs  in  the  food. 

The  experiments  of  Strasser  prove  conclusively  that  the  second  object, 
viz.,  increasing  the  elimination  of  nitrogen,  salines  and  water,  is  best  accom- 
plished by  the  systematic  use  of  hydrotherapy ;  and  that  what  has  been 
vainly  hoped  from  diuretic  drugs  is  produced  by  bathing.  His  experiments 
were  largely  with  the  full  warm  bath  at  95°  to  100°  F.  In  all  cases,  there  was 
a  decided  increase  in  the  quantity  of  urine  and  chlorides  excreted,  which 
frequently  continued  several  days  after  the  cessation  of  treatment.  In  no 
case  was  there  a  storage  of  nitrogen  or  salines  on  the  bath  days.  This  was 
true  alike  of  cases  having  edema  and  where  there  was  no  decrease  in  the 
chlorides  or  nitrogen  in  the  diet.  The  full  warm  bath  frequently  increased 
the  elimination  of  sodium  chloride  two  or  three  times  the  usual  amount.  In 
one  case,  increase  in  the  nitrogen  and  sodium  chloride  of  the  urine  occurred 
without  increase  in  the  total  amount  of  urine  and  continued  for  three  days 
after  the  treatment. 

Relative  to  the  relation  of  the  two  crystalloids,  glucose  and  sodium  chlo- 
ride, to  dropsy  and  diuresis,  some  interesting  facts  have  been  pointed  out  by 
Starling.  While  the  presence  of  unusual  amounts  of  glucose  in  the  circu- 
lating fluid  induces  diuresis  at  the  ultimate  expense  of  the  tissue  fluids,  the 
chronic  ingestion  of  much  salt  does,  under  certain  circumstances,  tend  to 
increase  the  tissue  fluids  and  limit  diuresis,  producing  a  "water  logged" 
condition. 

"If  a  solution  of  30  grains  of  glucose  in  about  30  cubic  centimeters  of 
water  be  injected  into  the  jugular  vein,  the  first  effect  is  a  great  increase 
in  the  volume  of  the  circulating  blood,  brought  about  by  the  osmotic  attrac- 
tion of  water  into  the  vessels  at  the  expense  first  of  the  tissue  spaces,  but 
ultimately  of  the  tissue  cells.  The  consequence  of  the  hydremic  plethora 
thereby  induced  is  increased  circulation  through  the  kidneys  and  increased 
output  of  urine  containing  large  quantities  of  sugar.  .  .  .  Under  ordi- 
nary circumstances,  the  concentration  of  the  tissues  thus  induced  would 
produce  intense  thirst  and  increased  intake  of  water,  so  that  the  urinary 

8    J.  H.  Mussei — Causes  of  Hypertension  in  Nephritis — Journal  of  American  Medical  Associa- 
tion, November  27,  1909,  p.  1791. 


212  DIURETIC  EFFECTS 

flow  would  be  maintained  at  a  high  level  until  the  whole  excess  of  the  glu- 
cose had  been  excreted."9 

"The  ingestion  of  an  excessive  quantity  of  salt  provokes  thirst  rather  than 
diuresis.  If  this  excessive  ingestion  were  continued  or  became  chronic, 
there  would  be  a  tendency  for  the  amount  of  this  salt  in  the  body  to  contin- 
ually increase,  the  salt  being  associated  with  sufficient  water  to  maintain 
the  molecular  concentration  of  the  body  fluids  at  their  normal  height.  It  is 
not  surprising,  therefore,  that  excessive  quantities  of  salt  have  been  found 
to  exert  a  deleterious  influence  in  cases  of  dropsy,  or  that  marked  benefits 
as  regards  the  reduction  of  dropsy 'have  been  attained  by  the  limitation  of 
salt  in  the  diet."  10 

Edema  is  lessened  by  warm  or  sweating  baths  and  sometimes  very 
promptly.  The  dropsy  responds  even  more  promptly  to  alternate  hot  and 
cold  applications  to  the  edematous  parts.  The  rationale  of  these  hydriatic 
effects  in  lessening  edema  is  a  very  interesting  study.  We  have  already 
dwelt  quite  at  length  upon  the  vascular  changes  produced  by  alternating 
thermic  applications.  Starling  has  recently  correlated  present  knowledge 
regarding  the  causation  of  dropsy.  In  the  summary  he  brings  out  a  number 
of  practical  points.  "Ranvier  has  shown  that  if,  after  ligature  of  the  infe- 
rior vena  cava,  the  sciatic  nerve  be  divided  on  one  side  so  as  to  produce 
dilatation  of  the  arterioles  on  that  side,  the  limb  in  which  the  nerve  has  been 
divided  will  become  edematous."11  There  must  be  other  factors  beside 
venous  obstruction  if  edema  is  to  result.  Starling  concludes  that  the  deter- 
mining cause,  other  than  stasis,  lies  in  an  increased  permeability  of  the  ves- 
sel wall.  This  is  due  in  disease  to  lack  of  the  proper  nutrition  and  oxygen 
supply  to  the  cells  of  the  vessel  wall.  "Cohnheim  showed  that,  after  long 
continued  anemia  of  the  rabbit's  ear,  the  vessels  became  so  permeable  that 
restoration  of  the  normal  circulation  was  followed  by  pronounced  edema  of 
all  the  tissues."  12 

The  same  results  were  obtained  by  Barlow.  This  anemia  resulted  in 
asphyxia  and  starvation  of  the  cells.  A  long  continued  venous  stasis  must 
affect  the  vessel  walls  in  much  the  same  way,  since  it  also  decreases  the 
oxygen  and  nutritive  supply.  In  chronic  nephritis  there  is  usually  a  marked 
anemia  with  hydremic  blood  and  this  appears  before  the  edema.  From 
experiments  by  Bolton,  one  may  conclude  that  edema  results  solely  because 
of  this  series  of  changes  occasioned  by  the  stagnation  of  blood  in  dilated 
veins  and  that  plethora  or  increased  capillary  tension  are  neither  of  them 
necessary  for  the  production  of  edema.  These  facts  have  led  Starling  to 
the  belief  that  alterations  in  the  endothelium  of  the  capillary  wall  must  be 
regarded  as  the  essential  factor  in  the  production  of  edema.  The  retention 
of  nitrogenous  wastes  in  nephritis  must  be  an  added  cause  of  injury  to  the 
vessels.  With  these  facts  in  mind,  the  rationale  of  hydriatic  treatment  is 
quite  evident.  The  restoration  of  tone  to  the  vessels,  both  blood  and  lymph, 
hastens  the  circulation,  thus  relieving  the  stasis  and  consequently  improv- 
ing the  nutrition  of  the  vessel  walls.  The  nutritive  processes  and  activity 

9  Starling:— Fluids  of  the  Body,  p.  153. 

10  Ibid.,  p.  154. 

11  Ibid.,  p.  159. 

12  Ibid.,  p.  162. 


ACUTE  NEPHRITIS  213 

of  the  endothelial  cells  are  directly  stimulated  by  hydriatic  applications.  In 
short,  the  entire  series  of  morbid  changes  from  the  decreased  permeability 
of  the  kidneys  to  the  venous  stasis  and  increased  permeability  of  the  vessel 
walls,  is  met  by  the  one  agent — warm  water.  There  is  no  evidence  that 
free  water  drinking  is  harmful  in  edema  where  the  amount  of  urine  is 
less  than  normal.  On  the  contrary,  it  has  been  shown  that  plethora  is  not 
a  contributing  factor  in  edema.  The  diuresis  it  induces  greatly  lessens  nit- 
rogenous retention  and  thus,  by  decreasing  the  toxemia,  aids  recovery. 

Acute  -Nephritis.  Beginning  as  it  does  as  an  acute  inflammation  and  pas- 
sing through  the  various  stages  of  the  inflammatory  process,  acute  Bright's 
disease  should  be  treated  along  the  lines  laid  down  for  inflammations.  The 
peculiar  course  of  the  disease  is  governed  by  the  anatomic  and  physiologic 
relations  of  the  kidneys,  organs  of  necessarily  constant  activity,  and  activ- 
ity of  such  a  character  that  it  must  militate  against  their  recovery.  The  kid- 
ney is  congested,  swollen,  edematous  and  tense  at  the  onset  of  the  first 
symptoms;  later,  venous  stasis  is  the  predominating  physical  change.  To 
relieve  these  conditions  sweating  measures  have  abundantly  proven  their 
superiority.  These  congest  the  skin  and  relieve  the  kidney  congestion.  The 
patient  should  perspire  freely  for  an  hour  or  more,  at  least  once  a  day.  The 
skin  should  be  warm  and  moist  all  of  the  time.  Free  diaphoresis  may  be 
accomplished  in  several  ways.  It  is  often  best  to  resort  to  some  of  the 
milder  measures,  such  as  the  hot  foot  bath  with  fomentations  to  the  abdo- 
men or  spine,  or  the  hot  trunk  pack.  If  the  symptoms  are  urgent,  the"  full 
hot  pack  may  be  used.  The  head  should  be  kept  cool  and  if  the  pulse  is 
over  100,  an  ice  bag  placed  over  the  heart.  During  the  sweat,  copious  water 
drinking  should  be  encouraged.  This  favors  diaphoresis  and,  as  soon  as  the 
renal  congestion  lessens,  it  aids  in  diuresis.  The  patient  may  be  sponged  off 
with  tepid  water  and  then  placed  between  warm  blankets  to  continue  per- 
spiring gently  for  an  hour  or  longer.  A  brisk  cold  mitten  friction  so  given 
that  the  part  treated  is  immediately  dried,  rubbed  with  the  dry  hand  until 
warm,  and  then  covered  with  the  warm  dry  blanket,  will  prove  a  valuable 
adjunct  to  the  sweating  measure.  It  improves  the  general  vitality  and 
helps  restore  the  cardio-vascular  mechanism  to  normal  tone.  General  cold 
applications,  i.  e.,  cold  applied  to  a  large  surface  at  one  time,  such  as  the 
cold  towel  rub  or  wet  sheet  are  counterindicated.  The  cold  mitten  friction 
given  as  described  above  counteracts  the  depressing  tendency  of  the  sweat- 
ing measures  which  must  be  repeated  daily.  The  alcohol  rub  may  be  used, 
but  it  lacks  the  tonic  effect  obtained  from  the  cold.  The  hot  air  bath,  so 
prepared  that  it  can  be  given  in  bed,  is  an  excellent  means  of  producing 
perspiration.  Croftan  1S  objects  to  the  use  of  dry  heat  in  cases  unaccom- 
panied by  edema,  claiming  that  it  increases  the  concentration  of  the  blood. 
He  favors  the  use  of  the  full  warm  bath  in  acute  nephritis.  This  should  be 
at  a  temperature  of  98°  to  104°  F.,  continued  for  ten  or  fifteen  minutes. 
Others  recommend  a  temperature  not  over  100°  F.,  in  subacute  nephritis 
and  the  prolonging  of  the  bath  from  thirty  to  sixty  minutes.  During  this 
time,  the  head  and  face  should  be  bathed  in  cold  water  or  cold  compresses 
applied  to  the  head  and  neck.  The  tub  ought  to  be  covered  with  a  sheet  in 
order  to  limit  the  cooling  of  the  surface  and  when  the  patient  is  removed, 

13    Clinical  Therapeutics. 


214  DIURETIC  EFFECTS 

the  room  temperature  must  be  85°  or  more  to  guard  against  chilling.  The 
patient  should  be  immediately  placed  between  dry  blankets,  or  in  a  sheet  and 
well  covered  by  warm  dry  blankets  and  allowed  to  remain  in  this  heating 
pack  for  a  time.  The  electro-thermal  pack  is  a  very  convenient  substitute 
for  the  dry  pack. 

During  the  first  few  days  of  acute  nephritis,  in  case  it  seems  necessary  to 
use  the  hot  trunk  pack  or  full  hot  blanket  pack,  an  ice  bag  may  be  applied 
over  the  lower  third  of  the  sternum.  Its  tends  to  cause  reflex  vasoconstric- 
tion  in  the  kidney.  With  these  intensely  hot  applications,  an  ice  .bag  over 
the  heart  is  usually  necessary  and,  if  a  large  ice  cap  is  used,  it  will  cover  the 
sternal  kidney  area  as  well.  Other  forms  of  hot  bath,  such  as  the  Russian 
and  electric  light,  may  be  best  left  for  subacute  or  chronic  nephritis  after 
the  acute  symptoms  have  largely  subsided. 

Chronic  Nephritis.  In  chronic  nephritis,  whether  a  sequel  of  the  acute  or 
coming  on  insidiously  and  complicated  by  cardiac  and  vascular  changes,  it  is 
possible  to  utilize  a  greater  variety  of  measures  and  more  vigorous  tonics 
can  be  borne.  A  southern  climate  is  of  advantage  largely  because  free  per- 
spiration is  secured  without  effort  and  there  is  less  tendency  to  chilling.  We 
have  utilized  with  success  all  of  the  hot  baths,  such  as  the  Russian,  Turkish, 
electric  light  and  superheated  air.  These  may  be  given  two  or  three  times 
a  week.  About  once  a  week  or  once  in  two  weeks,  it  is  desirable  to  follow 
a  vigorous  sweating  treatment  by  the  Turkish  shampoo.  All  these  extreme 
sudorific  treatments  should  be  concluded  by  some  form  of  the  hot  and  cold 
shower,  douche  or  spray.  The  douche  is  the  best  means  since  it  combines 
percussion  effects  with  the  thermic  stimulus  and  so  lessens  the  tendency  to 
chilling.  The  alternate  application  of  fomentations  and  an  ice  bag  to  the 
lower  sternum  and  kidney  region  produces  mild  fluxion  in  the  kidney.  The 
alternate  hot  and  cold  percussion  douche  to  the  lower  sternum  and  the 
lower  dorsal  and  lumbar  regions  is  more  vigorous  and  a  very  efficient 
means  of  stimulating  renal  activity. 

Nearly  all  hydriatists  recommend  very  highly  the  full  warm  bath  as  the 
most  serviceable  measure  in  subacute  nephritis.  While  we  do  not  doubt  its 
great  utility,  yet  we  have  seen  better  results  by  employing,  in  about  two 
out  of  three  treatments,  more  vigorous  means  and  means  employing  more 
tonic  effects.  These  are  obtained  to  only  a  slight  extent  by  the  warm  bath. 
Where  there  are  marked  changes  in  the  heart  and  vessels,  we  have  found 
tonic  hydrotherapy  a  necessity.  Of  tonic  measures,  one  may  use  hot  and 
cold  to  the  spine,  the  revulsive  compress  to  the  kidney  region  or  abdomen, 
the  cold  mitten  friction,  the  ice  bag  to  the  heart  and  the  alternating  douche. 
The  Nauheim  bath  is  highly  recommended  both  for  the  relief  of  dropsy  and 
the  treatment  of  cardio-vascular  disturbance.  That  it  is  a  powerful  means 
can  not  be  doubted.  It  must,  however,  be  used  with  caution,  remembering 
that  it  may  result  in  overstimulation.  For  the  edema  of  the  feet  and  legs, 
alternate  hot  and  cold  immersion  is  as  valuable  as  for  the  same  condition  in 
cardiac  incompetency.  Its  beneficial  action  may  be  assisted  by  massage. 

Cathartics  and  Medicinal  Diaphoretics.  About  the  only  diaphoretic  drug 
recommended  as  a  routine  is  pilocarpin.  This  must,  however,  be  mentioned 
only  to  be  condemned.  It  is  dangerous  where  the  heart  may  be  involved  in 
the  general  vascular  changes  and  its  use  is  entirely  superfluous  since  we 


UREMIA  AND  ECLAMPSIA  215 

have  such  efficient  hydriatic  means  of  accomplishing  the  same  results.  Saline 
cathartics  or  elaterium  as  a  means  of  reducing  ascites  or  anasarca  may  at 
times  seem  necessary.  Their  repeated  use  is  not  to  be  encouraged,  since 
they  induce  great  weakness  and  derange  the  digestion.  It  is  necessary  that 
special  attention  be  paid  to  gastric  digestion.  The  measures  recommended 
for  the  various  forms  of  atonic  indigestion  should  be  used  as  indicated. 
Attention  should  also  be  given  the  gastrectasia  which  so  frequently  accom- 
panies a  chronic  parenchymatous  nephritis.  It  is  a  cause  of  faulty  nutrition 
and  is  closely  connected  with  morbid  proteid  metabolism.  The  free  use  of 
mineral  waters  may  greatly  increase  the  dilatation.  Fluids  must  be  taken 
in  .small  amounts,  preferably  as  plain  cold  water.  In  interstitial  nephritis, 
mineral  waters  or  even  the  free  use  of  ordinary  water  is  unnecessary,  since 
diuresis  is  the  rule.  In  this  form,  whether  simple  or  forming  part  of  a  gen- 
eral arteriosclerosis,  extreme  measures,  either  hot  or  cold,  are  counterindi- 
cated  since  the  increase  of  blood  pressure  which  both  produce  may  determine 
an  apoplexy.  Mild  diaphoresis  is  beneficial  and  this  may  be  secured  by  short 
hot  baths  or  the  prolonged  neutral  bath  at  a  temperature  of  95°  or  96°. 
This  tends  to  equalize  the  blood  pressure  and  helps  to  relieve  the  nerve  ten- 
sion which  is  a  part  of  the  clinical  picture  in  many  of  these  cases. 

It  has  recently  been  shown  that  the  endogenous  uric  acid  in  the  blood  in 
interstitial  nephritis  varies  according  to  the  functional  activity  of  the  kid- 
neys. 14  These  observations  were  made  on  a  purin-free  diet.  This  retention 
of  uric  acid  is  favorably  influenced  by  exercise  and  hydrotherapy.  Umber 
noticed  that  on  a  purin-free  diet  the  elimination  of  uric  acid  decreased  after 
exercise,  owing  to  its  participation  in  the  increased  oxidation  incident  to 
muscular  exertion.  That  like  results  may  be  obtained  by  hydrotherapy  has 
been  shown  by  the  researches  of  Strasser. 


Uremia  and  Eclampsia 

These  pathologic  states,  while  not  identical,  have  many  points  in  common. 
In  uremia,  there  is,  in  the  majority  of  cases,  a  retention  of  toxic  urinary 
products  because  of  the  kidney  insufficiency.  While  all  observers  are  not 
agreed  as  to  the  constant  occurrence  of  kidney  insufficiency  in  eclampsia, 
yet  nearly  all  agree  that  its  manifestations  are  accompanied  by  a  severe 
poisoning  from  some  autotoxic  source.  Croftan  says  there  is  much 
chemical  and  clinical  evidence  to  show  that  in  uremia  the  general  metabol- 
ism and,  in  particular,  the  manifold  functions  of  the  liver,  are  perverted. 
The  kidney  may  not  be  primarily  involved  and  possibly  in  some  few  cases 
not  at  all.  In  the  majority  of  cases,  however,  there  are  demonstratable 
lesions  in  the  kidney  as  well  as  functional  inadequacy  during  life.  A  great 
variety  of  conditions  have  been  reported  among  which  are  infarcts,  acute 
and  chronic  congestion,  edema,  greatly  increased  tension  and  actual  nephri- 

14  In  gout  the  endogenous  uric  acid  in  the  blood  is  more  constant  and  never  exceeds  a  certain 
maximum  amount  (about  0.003  per  cent)  A  demonstratable  amount  of  uric  acid  is  always  pres- 
ent in  the  blood  in  gout,  even  when  the  food  has  been  free  from  purins  for  weeks  or  months, 
while  blood  from  normal  individuals  on  a  purin-free  diet  contains  no  uric  acid. — Journal  of  Ameri- 
can Medical  Association,  April  3,  1909,  p.  1110. 


216  DIURETIC  EFFECTS 

tis.  In  a  case  of  eclampsia  reported  by  Wiemer 1S  the  tension  was  so  marked 
that  the  kidney  substance  bulged  out  on  incision  in  the  course  of  Edebohl's 
operation.  Braak  and  Mijnlieff  I6  report  a  case  in  which  the  right  kidney 
was  much  enlarged  and  so  painful  that  the  patient,  in  coma,  reacted  when 
it  was  palpated.  They  report  13  other  cases  of  eclampsia  accompanied  by 
increased  tension  in  the  kidney.  •  All  were  treated  by  decapsulation  and, 
with  one  exception,  recovered.  Franck  reports  10  cases  with  no  bulging  or 
increased  intracapsular  tension. 

Hepatic  changes  are  almost  universally  present.  In  fact,  functional  and 
structural  alterations  of  the  kidneys  and  liver  are  very  frequently  associated. 
Their  function^  are  consecutive,  i.  e.,  the  liver  is  the  chief  agent  in  the  pre- 
parations of  wastes  for  excretion  and  the  kidneys  receive  these  for  purposes 
of  excretion.  This  naturally  leads  to  the  view,  which  is  also  supported  by 
clinical  analyses,  that  in  many  cases  the  decrease  of  urea  in  the  urine  is  due 
not  to  failure  in  its  elimination,  but  to  failure  in  its  formation  from  the 
various  precursors,  including  the  ammonia  compounds;  uremia  then,  being 
due  to  these  toxic  antecedents,  rather  than  to  poisons  retained  with  the  urea, 
and  of  the  amount  of  which  the  decreased  urea  excretion  is  a  gauge.  "Some- 
where in  the  organism  there  is  a  deficient  changing  of  ammonia  and  amino- 
acids  into  urea.  This  has  been  called  'deficient  desamidation'  by  Ewing, 
who  asserts  that  the  process  is  no  more  than  an  oxidation.  This  work  is  in 
a  great  measure  performed  by  the  liver,  and  therefore  we  are  not  surprised 
to  find  the  liver  most  severely  involved."  u 

In  this  connection  it  is  interesting  to  note  the  relation  of  one  of  the  chief 
causes  of  uremia  and  eclampsia,  viz. ,— a  diet  rich  in  meat, — to  the  size  of  the 
liver.  Dr.  Chalmers  Watson  18  calls  attention  to  the  difference  in  the  size  of 
the  liver  in  meat-fed  rats  and  in  bread-and-milk-fed  rats.  From  an  exami- 
nation of  the  livers  in  the  two  cases  it  was  shown  that  the  average  liver 
weight  of  the  meat-fed  rats  was  6  grams,  while  the  average  liver  weight  of 
the  bread-and-milk-fed  rats  was  4  grams.  The  meat. diet  had  caused  an 
increase  of  50  per  cent  in  the  size  of  the  liver. 

Moreover  it  has  been  shown  that  a  severe  acidemia  may  cause  the  convul- 
sions and  coma  characteristic  of  uremia  and  eclampsia.  Were  this  the  case, 
sweating  treatment,  if  much  prolonged,  would  only  deepen  the  difficulty  since, 
if  unaccompanied  by  cold,  it  increases  the  acidosis. 

For  practical  purposes,  we  may  divide  the  treatment  into  two  parts:  First, 
the  treatment  of  chronic  uremia,  the  conditions  that  predispose  to  the  acute 
attack,  and  the  pre-eclamptic  state.  Second,  the  treatment  of  the  acute 
attack  of  uremia  or  eclampsia,  the  convulsive  seizures  and  coma.  It  should 
be  borne  in  mind  that  in  .eclampsia  a  neurotic  temperment  predisposes  to 
the  attack  and  that  there  is  the  added  factor  of  pregnancy  which  may,  in 
spite  of  vigorous  treatment,  demand  hasty  emptying  of  the  uterus. 

"Chronic"  Uremia  and  the  Pre-eclamptic  State.  The  principles  involved 
in  the  treatment  of  faulty  nitrogenous  metabolism  have  been  discussed  in 

15  Monatschrift  fur  Geburtsh  und  Gynakoloprie,  March,  1908. 

16  Centralblatt  fur  Gynakologie,  October  19,  1908. 

17  Davis  and  Foulkrod— The  Etiology  of  Eclampsia, — Journal  of  American  Medical  Association, 
January  7,  1911,  pp.  11,  12. 

18  London  Lancet,  October  12,  1907. 


Llll-    ,~^. 


ACUTE  UREMIA  AND  ECLAMPSIA  217 

the  consideration  of  rheumatism  and  Bright's  disease.  Those  persons  living 
upon  a  highly  nitrogenous  diet,  containing  purins,  are  predisposed  to  the 
uremic  state.  Women  who  partake  heavily  of  tea  and  coffee  are  predisposed 
to  eclampsia.  The  reason  for  this  is  that  the  caffein  greatly  increases  the 
amount  of  basic  purins  which  must  therefore  be  raked  over  by  the  liver  and 
thrown  out  by  the  kidneys. 

Alfred  Schittenhelm  19  has  shown  by  experiments  upon  dogs  the  extent  to 
which  caffein  increases  basic  purins  and  uric  acid.  We  give  below  a  table 
of  averages  showing  these  items.  The  dog  was  kept  on  a  purin-free  diet 
previous  to  the  tests.  The  pre-period  lasted  3  days.  For  3  days  following 
this,  three  daily  doses  each  of  0.3  grams  of  caffein  were  administered.  Next 
intervened  a  period  of  2  days  with  purin-free  diet,  and  following  this  the 
same  daily  amount  of  theobromin  (as  previously  of  caffein)  was  given  for  2 
days. 

Caffein  Inter-      Theobromin        After 

Pre-period       period  period  period  period 

Uric  acid  in  gm.  N.  0.006         0.008         0.006         0.007         0.006 

Purin  bases  in  gm.  N.  0.005         0.026          0.009          0.013         0.008 

Chronic  congestion  of  the  liver  as  pointed  out  above  and  hepatic  cirrhosis 
are  also  factors  in  the  causation  of  uremia.  The  vicious  cycle  and  disordered 
liver  accompanying  periodic  sick  headaches  are  additional  causes.  These 
conditions  demand  the  exclusion  of  purins  (meat,  tea  and  coffee)  from  the 
diet,  and  the  limitation  of  proteins.  The  diet  should  consist  largely  of 
carbohydrates,  milk,  fresh  vegetables  and  fruits.  Hydriatic  treatment 
should  be  directed  toward  the  oxidation  and  elimination  of  nitrogenous 
wastes.  As  a  means  to  this  end,  special  attention  should  be  given  to  the 
liver  activity,  the  circulation  and  renal  activity.  Extreme  diaphoresis  is 
not  necessary,  but  gentle,  free  perspiration  should  be  encouraged.  To  this 
"end,  short  electric  light  baths  may  be  used  once,  a  week.  More  or  less  per- 
spiration accompanies  the  use  of  local  hot  applications,  such  as  the  hot  foot 
bath  with  fomentations  to  the  abdomen  and  spine,  warm  showers  and  douches. 
A  regular  course  of  tonic  treatment  should  accompany  these  measures:  of 
these,  mny  be  used  hot  and  cold  to  the  spine,  revulsive  compress,  cold  fric- 
tions, alternate  showers,  sprays  and  douches.  The  neutral  or  warm  tub  bath 
is  an  excellent  means  of  quieting  nervous  symptoms  and  equalizing  blood 
pressure.  The  patient  should  drink  water  freely  and  frequently".  Fomen- 
tations and  the  revulsive  compress  to  the  liver,  also  the  alternate  douche  to  the 
hepatic  region  are  efficient  chologogues  and  stimulate  all  the  other  hepatic 
functions.  In  case  pregnancy  is  complicated  by  a  pre-existing  nephritis,  the 
patient  should  be  under  constant  observation  and  treatment.  The  measures 
recommended  for  chronic  Bright's  disease  may  be  employed. 

Acute  Uremia  and  Eclampsia.  So  successful  have  diaphoretic  measures 
proven  in  these  conditions  that  they  are  almost  specific.  The  repeated  use 
of  prolonged  sweating  treatments  is  not  advisable  unless  there  is  a  favor- 
able response  from  the  first  or  second  application.  The  measure  which  has 
given  the  best  result  is  the  full  hot  blanket  pack  accompanied  by  the  inges- 
tion  of  an  abundance  of  water.  It  may  be  necessary  to  use  saline  solution 

19  Zur  Frage  der  harnsaurevermehrenden  Wirkung  von  Kaffee  und  Tee  und  ihrer  Bedeutung 
in  der  Gichttherapie — Therapeutische  Monatshefte,  March,  1910,  p.  115. 


218  DIURETIC  EFFECTS 

by  hypodermoclysis  or  enteroclysis.  This  can  not  result  in  damage  from 
increase  of  blood  pressure  if  the  patient  is  perspiring  freely.  Many  cases 
have  been  reported  in  which  the  giving  of  saline  solution  resulted  in  prompt 
diuresis.  It  dilutes  the  blood,  decreases  the  toxemia  and  favors  elimination 
by  the  skin  and  kidneys.  It  may  be  necessary  to  somewhat  prolong  the  hot 
pack.  Whenever  it  is  used,  the  cerebral  circulation  should  be  guarded  by 
the  cold  compress,  ice  bag  or  cold  affusions  to  the  head.  An  ice  bag  should 
also  be  used  over  the  heart.  The  patient  may  be  removed  from  the  pack  by 
a  wet  hand  rub  or  other  cold  friction  and  put  between  blankets  to  continue 
perspiring  gently.  Croftan,  Edwards  and  others  favor  the  use  of  the  full 
hot  bath  as  recommended  by  Liebermeister.  The  bath  begins  at  98°  or 
thereabouts  and  is  generally  run  up  5°  or  6°,  the  head  being  kept  cool  by 
cold  affusions. 

The  rationale  of  these  sweating  treatments  lies  not  alone  in  the  elimina- 
tion of  toxins  by  the  skin.  In  fact,  we  believe  this  is  only  a  part  and 
perhaps  often  a  small  part  of  the  real  effect.  Soon  after  free  diaphoresis 
has  been  established,  urinary  secretion  begins  to  increase  and  may,  in  acute 
suppression,  appear  very  promptly.  This  is  doubtless  due  to  the  relief  of 
the  kidney  congestion  and  the  reduction  of  renal  edema  and  increased  ten- 
sion in  those  cases  in  which  these  occur.  Relieving  renal  stasis  always 
results  in  freer  excretion  of  urine.  The  case  of  eclampsia  with  great  enlarga- 
ment  of  the  kidney  mentioned  above  as  reported  by  Braak  andMijnlieff,  hav- 
ing refused  operation,  recovered  under  the  use  of  wet  packs  with  hot  water 
bottles  and  medicinal  measures.  The  coma  subsided  and  the  kidney  gradu- 
ally returned  to  normal  size.  0.  M.  Hay  ward20  reports  a  case  of  eclampsia 
in  which  two  hot  packs  failed  to  relieve  the  coma.  With  the  patient  deeply 
comatose,  pulse  160  and  very  weak,  axillary  temperature  105.2°  F.,  and  res- 
piration irregular  and  gasping,  she  was  wrapped  in  a  sheet,  placed  on  a 
table,  and  a  cold,  rubbing  pour  administered.  In  five  minutes,  there  was- 
some  improvement  and  the  cold  pour  and  rubbing  were  continued.  In  thirty 
minutes,  the  patient  was  returned  to  bed  with  a  temperature  of  100°  F., 
pulse  100  and  respiration  nearly  normal.  The  failure  in  the  hot  pack  was 
doubtless  due  to  the  fact  that  it  was  unaccompanied  by  a  cold  friction.  This 
might  have  been  administered  by  the  cold  mitten  or,  as  was  done  later,  by 
the  cold  pour  and  rubbing  wet  sheet  pack. 

The  use  of  a  large  ice  cap  to  the  heart  and  over  the  lower  third  of  the 
sternum  will  prevent  any  damage  to  the  heart  which  might  result  from  the 
sweating  treatment  and  serve  also  to  cause,  reflexly,  contraction  of  the  kid- 
ney vessels  and  thus  lessen  congestion  and  intracapsular  tension. 

20    Modern  Medicine,  March,  1908,  p.  60. 


CHAPTER  XXV 
PEPTOGENIC  EFFECTS 


This  term  "peptogenic  effects"  is  here  used  to  designate  a  variety  of 
effects  upon  the  digestive  organs  and  digestive  activity  in  the  sense  of 
increasing  the  efficiency  of  these  organs  and  functions.  The  measures  di- 
rected toward  improving  the  digestion  also  increase  the  activity  of  the  liver. 
All  tonic  treatments  increase  the  muscular  and  glandular  activity  of  the 
stomach  and  intestines,  also  the  glandular  activity  of  the  liver  and  pan- 
creas. They  aid  digestion  and  sharpen  the  appetite.  In  addition  to  gen- 
eral tonic  treatments,  it  is  necessary  to  direct  special  attention  to  the  diges- 
tive organs  themselves.  The  following  are  some  of  these  special  treatments 
which  are  useful  in  promoting  digestion  and  absorption: — 

1.  Winternitz  pack  (hot  and  heating  trunk  pack). 

2.  Hot  trunk  pack. 

3.  Fomentations  to  the  abdomen. 

4.  Revulsive  compress  to  the  abdomen. 

5.  Hot  and  cold  to  the  spine. 

6.  Hot  and  cold  douche  to  the  abdomen,  liver  and  spine. 

7.  The  Umschlag  (moist  abdominal  girdle). 

8.  Hot  water  bottle  or  Winternitz  coil  over  the  stomach  after  a  meal. 

9.  Ice  bag  over  the  stomach,  or  cold  water  drinking,  before  a  meal. 

These  treatments  properly  selected  to  meet  the  needs  of  the  individual 
case  are  indicated  in, — 

1.  All  forms  of  atonic  indigestion. 

a.  Hypochlorhydria. 

b.  Anacidia. 

c.  Gastrectasia. 

d.  Gastroptosis. 

e.  Lowered  gastric  motility. 

f.  General  splanchnoptosis. 

g.  Biliousness. 

h.     Periodic  sick  headaches  (in  interval), 
i.     Amlaceous  dyspepsia. 

2.  Chronic  congestion  of  liver. 

3.  Anemia  of  liver. 

Atonic  Dyspepsia 

This  term  is  not  used  in  its  ordinary  restricted  sense  as  applying  alone  to 
painful  digestion.  We  use  it  here  to  designate  a  great  variety  of  digestive 


220  PEPTOGENIC  EFFECTS 

disorders  associated  with  deficient  gastric  secretion,  and  lessened  motility 
with  more  or  less  distress  or  discomfort  after  meals.  These  various  condi- 
tions may  be  grouped  in  this  manner  for  convenience  in  considering  their 
hydriatic  management,  for  this  must  be  carried  on  along  much  the  same  lines 
in  all.  The  aim  is  to  produce  a  general  increase  of  tone  in  both  the  glands 
and  musculature  of  the  digestive  organs.  We  hardly  need  mention  that 
special  attention  must  be  paid  to  the  matter  of  diet,  exercise,  rest,  favor- 
able environment,  etc.  These  are  all  of  prime  importance. 

In  the  more  severe  grades  of  defective  digestion,  something  like  the  fol- 
lowing program  should  be  carried  out: — 

Half  an  hour  before  the  meal,  the  patient  should  be  instructed  to  take 
half  a  glass  of  cold  water  or  even  ice  water.  Bits  of  ice,  or  a  small  amount 
of  a  fruit  ice  may  be  taken  20  minutes  to  half  an  hour  before  the  meal. 
Instead  of  cold  internally,  an  ice  bag  may  be  placed  over  the  stomach  begin- 
ning half  or  three  quarters  of  an  hour  before  the  meal  and  continued  for  10 
or  15  minutes.  The  skin  over  the  stomach  should  warm  up  before  the  meal 
is  taken.  This  will  require  about  15  minutes  after  the  ice  bag  has  been 
removed.  The  philosophy  of  these  measures  lies  in  the  fact  that  the  cold 
application  produces  a  reaction  which  comes  on  at  the  time  the  meal  is  taken 
so  that  the  glandular  activity  is  increased  during  the  period  of  digestion. 

The  experimental  basis  of  this  old  and  very  successful  means  of  promoting 
gastric  secretion  has  been  worked  out  by  Doctor  Kasanski  in  the  laboratory 
of  Prof.  I.  P.  Pavlov.  '  By  the  application  of  cold  the  activity  of  the  gas- 
tric glands  is  arrested  while  the  cold  continues.  After  the  removal  of  the 
cold,  the  work  of  the  glands  rises  above  the  normal  and  continues  at  a  higher 
point  for  a  longer  time.  In  the  following  table  will  be  noted  the  result  of 
intense  cold  applied  during  the  first  hour  of  the  digestive  period.  The  reac- 
tion comes  on  during  the  second  hour. 

Hour  Normal  Secretion  Secretion  as 

Affected  by  Cold 

1st  11.6  c.  c.                                            6.2  c.  c. 

2nd  8.4    "  11.6     " 

3rd  3.5    "    .  10.8     " 

4th  1.9    "                                                   5.6     " 

5th  1.3    "                                                   3.6     " 

Following  the  meal,  the  patient  should  use  a  hot  water  bottle  over  the 
stomach.  This  should  be  coutinued  for  20  minutes  to  an  hour,  or  even 
longer.  In  more  severe  cases,  the  Winternitz  pack  will  be  found  very  effi- 
cient. It  should  be  applied  immediately  following  the  meal,  or  the  pack 
may  be  applied  first  and  the  meal  eaten  while  the  patient  is  in  the  pack.  It 
should  be  continued  for  from  30  minutes  to  as  long  as  2  or  3  hours  and  be 
concluded  with  a  cold  mitten  friction.  In  applying  the  pack  the  hot  water 
bottle  may  be  used  in  place  of  the  Winternitz  coil.  Since  a  constant  tem- 
perature can  not  be  maintained  by  the  hot  water  bottle,  the  treatment  is 
not  so  effectual.  Fomentations  of  moderate  heat  may  be  applied  to  the 
abdomen  over  the  stomach  and  liver,  immediately  following  a  meal.  Two 
or  three  hours  after  the  meal,  the  patient  may  be  given  a  treatment  con- 

1     WorU  of  the  Digestive  Glands,  Second  English  Edition,  pp.  239,  240. 


ATONIC  DYSPEPSIA  221 

sisting  of  a  hot  foot  bath  with  a  revulsive  compress  to  the  abdomen,  or  hot 
and  cold  to  the  spine,  together  with  the  cold  mitten  friction  or  cold  towel 
rub.  Other  applications  which  may  be  used  are  the  hot  and  cold  douche  to 
the  abdomen  and  liver,  also  to  the  spine.  At  night  it  is  well  to  apply  the 
moist  abdominal  girdle.  It  should  be  dry  by  morning.  The  protected  girdle 
is  not  used  in  this  condition. 

In  addition  to  these  hydriatic  measures,  the  patient  should  be  given  general 
massage  with  special  abdominal  message,  vibration  to  the  abdomen,  faradic 
or  sinusoidal  electricity  to  abdomen  and  spine,  or  the  Morton  wave  to  the 
abdomen  and  spine.  Since  these  various  measures  are  not  applicable  to  all 
cases  of  atonic  dyspepsia,  they  should  be  selected  according  to  the  needs  of 
the  individual  case.  All  of  them,  with  the  exception  of  fomentations  to 
the  abdomen  and  the  hot  trunk  pack,  are  counterindicated  in  hyperchlor- 
hydria  and  gastric  or  duodenal  ulcer  with  much  hemorrhage. 

Patients  with  dyspepsia  soon  become  accustomed  to  cold  applications  and 
may  be  given  most  vigorous  tonics.  After  a  week  or  so  of  treatment  a 
general  cold  affusion  or  pail  pour  may  be  used  daily.  The  cold  wet  sheet 
rub  may  also  be  used  after  tolerance  for  douches  and  pail  pours  has  been 
acquired.  The  cold  morning  plunge  is  not  excelled  as  a  general  tonic  and 
exerts  a  beneficial  action  on  digestion.  It  sharpens  the  appetite,  thus  aiding 
in  the  production  of  "psychic  juice"  which  Pavlov  assures  us  is  5  times  as 
efficient  in  gastric  digestion  as  the  chemically  excited  secretion. 

Pavlov  has  further  shown  that  another  of  the  circumstances  favorable  to 
the  activity  of  the  gastric  glands  is  an  abundant  supply  of  water  in  the 
organism.  He  says,-  "One  of  these  favoring  circumstances  we  discovered 
in  the  introduction  of  large  quantities  of  water  into  the  system.  We  based 
this  upon  earlier  facts,  showing  that  the  quantity  of  juice  was  strikingly 
dependant  upon  the  amount  of  water  in  the  organism."  This  makes  clear 
the  necessity  for  free  water  drinking  between  meals  in  order  to  provide 
fluid  for  the  formation  of  the  requisite  amount  of  gastric  juice. 

In  cases  of  motor  insufficiency  associated  with  marked  dilatation,  cold 
drinks  can  not  be  used  before  the  meal  since  there  is  not  sufficient  power  to 
empty  the  stomach  in  so  short  a  time  and  the  circulatory  reaction  is  much 
delayed.  Before  the  meal,  the  patient  may  be  placed  on  a  table  or  slab  and 
a  cold  affusion  administered  to  the  abdomen.  This  should  be  intermittent, 
as  it  will  be  if,  by  means  of  a  large  dipper,  water  is  dipped  from  a  pail  and 
poured  over  the  abdomen.  The  temperature  of  the  water  at  first  should  be 
about  75°  F.  and  gradually  reduced  to  45°  or  50°  F.  One  full  pail  of  water 
will  usually  suffice  for  a  single  treatment. 

Douching  the  mucous  membrane,  i.  e.,  lavage  of  the  stomach,  with  cold 
water  may  be  found  helpful.  This  measure,  combined  with  intragastric 
electricity,  is  a  most  efficient  means.  After  swallowing  a  glass  of  cold  water 
the  gastric  electrode  is  introduced  and,  by  means  of  either  an  abdominal 
sponge  or  plate  placed  to  the  mid-dorsal  spine,  the  slow  sinusoidal  or  slow 
faradic  current  is  given  for  5  to  8  minutes.  One  may  frequently  hear  suc- 
cussion  sounds  or  the  gurgling  of  water  through  the  pylorus,  caused  by  vig- 
orous contractions  of  the  gastric  muscles.  These  treatments  may  be  given 
daily  or  on  alternate  days.  In  one  case,  a  month  of  such  treatment  with 

2    Ibid.,  p.  245. 


PEPTOGENIC    EFFECTS 

other  tonic  measures  resulted  in  a  retraction  of  the  greater  curvature 
toward  its  normal  position  of  one  and  one-half  inches  on  the  left  and  one 
inch  upward  in  the  median  line.  On  applying  for  treatment,  the  greater 
curvature  lay  three  inches  below  and  four  and  one-half  inches  to  the  left  of 
the  umbilicus. 

In  connection  with  the  use  of  gastric  lavage,  a  caution  should  be  uttered 
relative  to  the  frequent  use  of  large  quantities  of  warm  or  hot  water  intro- 
duced into  a  dilated  stomach.  The  relaxing  effect  is  very  marked  and  in 
the  course  of  months  or  years,  the  stomach  becomes  extremely  dilated 
and  entirely  loses  its  elasticity  and  contractility.  A  few  years  ago  the 
author  was  present  at  the  post  mortem  examination  of  a  man  who  had,  at 
frequent  intervals  for  a  number  of  years,  resorted  to  warm  gastric  lavage 
to  relieve  the  gastric  retention  and  fermentation  occasioned  by  an  extreme 
pyloric  stenosis.  The  stomach  was  found  to  be  enormous,  reaching  from 
the  greatest  height  of  the  f undus  at  the  level  of  the  fourth  intercostal  space 
on  the  left  to  the  level  of  the  anterior,  superior  spines  of  the  ilia,  2£  inches 
from  the  right  iliac  spine.  It  would  easily  hold  1£  or  2  gallons.  The  pylorus, 
for  a  distance  of  2  inches,  admitted  with  great  difficulty  a  small  size  lead 
pencil.  The  condition,  of  course,  should  have  been  treated  surgically  by 
some  form  of  pylorectomy. 

The  caution  here  is  not  against  systematic  washing  of  the  stomach  to  free 
it  from  decomposing  remnants  of  food  but  against  the  use  of  hot  water  for 
this  purpose.  If  it  seems  advisable  to  resort  to  gastric  lavage  frequently 
and  warm  water  is  used  first,  it  should  be  followed  by  a  "dash"  of  cold. 

In  those  cases  of  gastric  dilatation  and  lessened  motility  not  associated 
with  pyloric  obstruction,  hydriatic  means  produce  excellent  results.  In 
addition  to  the  measures  recommended  above,  the  alternate  hot  and  cold 
douche  to  the  epigastrium  may  be  used;  at  first,  with  little  or  no  force, 
later,  with  moderate  percussion.  The  percussion  douche  to  the  mid-dorsal 
spine,  also  to  the  legs  and  feet,  serves  as  a  vigorous  tonic.  Gastrectasia, 
associated  with  a  general  splanchnoptosis,  irritable,  tender  sympathetics, 
and  a  feeling  of  weight  and  dragging  in  the  abdomen  may  be  benefited  by 
the  cold  sitz-bath  begun  as  a  graduated  measure.  The  continuous  cold  coil 
to  the  abdomen  acts  in  the  same  way.  The  cold  sitz  may  be  prolonged  to 
5  or  6  minutes  and  the  cold  coil  left  in  place  20  to  30  minutes.  3 


Hy  perchlorhy  d  ria 

Nearly  all  cases  of  indigestion  pass  through  the  stage  of  hyperacidity  at 
the  beginning  of  the  departure  from  the  normal.  In  only  a  few,  however, 
is  this  condition  so  marked  as  to  require  special  treatment.  The  patient  is 
of  a  nervous  temperament,  and  eats  rapidly,  swallowing  his  food  with  very 
imperfect  mastication.  The  free  hydrochloric  acid  may  be  double  or  even 
treble  the  normal  amount.  The  course  to  be  followed  is  just  the  opposite 
to  that  outlined  for  hypochlorhydria.  The  patient  may  drink  hot  water  or 
use  a  hot  application  over  the  stomach  preceeding  the  meal,  after  which  an 

3    See  also  the  treatment  recommended  for  splanchnic  neurasthenia. 


HYPERCHLORHYDRIA  223 

ice  bag  should  be  used  for  20  to  30  minutes,  or  even  longer.  The  hot  water 
drinking  or  the  hot  application  to  the  epigastrium  produces  an  atonic  reac- 
tion. In  this  connection,  it  should  be  noted  that  among  the  experiments 
performed  by  Professor  Pavlov,  on  one  occasion  the  work  of  the  large  stom- 
ach was  arrested  for  several  days  by  the  application  of  very  hot  water. 
Thus  it  will  be  seen  that  by  applications  of  heat  of  a  suitable  temperature  an 
overactive  state  of  the  gastric  glands  may  be  depressed  and  their  activity 
be  brought  back  toward  normal. 

It  is  needless  to  say  that  dietetic  regulation  is  the  most  important  factor 
in  the  treatment  of  this  condition.  Oils,  whether  free  or  emulsified,  have  a 
specific  inhibitory  action  upon  the  secretion  of  hydrochloric  acid.  The  patient 
should  discard  the  use  of  meats  entirely.  Other  heavily  proteid  foods  should 
be  interdicted.  The  hyperacidity  may  be  lessened  by  the  use  of  the  protected 
or  sweating  moist  abdominal  girdle.  Tonic  treatments  should  be  replaced 
by  sedative  measures  such  as  the  neutral  bath,  neutral  pack  or  heating  pack. 
These  may  be  given  one  or  two  hours  before  a  meal  or  at  night. 


Capillary  hemorrhage  and  hemorrhage  from  smaller  blood  vessels  does 
not  usually  require  surgical  treatment.  Hemorrhage  into  the  hollow  organs 
tends  to  check  itself,  provided  the  circumstances  are  at  all  favorable,  so  that 
in  many  cases,  absolute  rest  accompanied  by  the  use  of  the  ice  bag,  may 
produce  all  that  is  desired.  Thermic  applications  may  be  made  directly  to 
the  part  or,  so  as  to  influence  the  blood  vessels  reflexly.  Cold  may  also  be 
used  over  the  trunk  of  the  artery  supplying  a  part.  If  heat  is  used  to  check 
the  hemorrhage,  the  application  must  be  very  hot  and  be  made  directly  to 
the  bleeding  part.  The  reflex  effect  of  even  very  hot  water  produces  only  a 
transient  narrowing  of  the  vessels,  while  in  a  short  time,  the  vessels  become 
dilated  and  the  hemorrhage  increases.  Cold  applications  may  be  used  either 
to  the  part  itself  or  to, the  reflex  area.  In  fact,  it  is  quite  a  general  rule 
that  cold  is  more  efficient  through  reflex  action,  while  hot  is  efficient  only 
when  applied  directly  to  the  bleeding  vessels.  In  nearly  every  case  where 
ice  is  used,  it  is  well  to  employ  some  hot  application  for  derivative  purposes. 
The  hot  should  not,  however,  produce  sweating  since  this  tends  to  dilate  the 
blood  vessels  and  increase  the  hemorrhage. 

Epistaxis 

Thermic  applications  are  often  very  effectual  in  treating  capillary  hemor- 
rhage from  the  nose.  Very  cold  water  or  very  hot  water  may  be  drawn 
into  the  nose.  An  application  of  ice  may  be  made  over  the  nose  itself.  Of 
the  more  remote  reflex  areas,  use  may  be  made  of  that  at  the  back  of  the 
neck  and  the  hands  by  having  the  patient  hold  a  chunk  of  ice  at  the  back  of 
the  neck.  The  hands  or  feet  may  be  placed  in  ice  water  or  very  cold  water 
for  a  short  time.  These  applications  should  not  produce  chilliness. 

Pulmonary  Hemorrhage 

The  patient  should  be  kept  at  absolute  rest.  Warmth  of  the  body  and 
limbs  should  be  maintained,  hot  water  bottles  being  placed  to  the  feet,  or, 
after  the  hemorrhage  has  somewhat  subsided,  the  patient  may  be  given  a 
hot  foot  bath.  That  which  is  of  most  importance  is  the  applying  of  an  ice 
bag  to  the  front  of  the  chest.  This  should  be  left  in  place  continuously  until 
all  danger  of  hemorrhage  is  past.  It  should  be  a  large  ice  bag  or  ice  cap. 
This  not  being  available,  the  ice  cqmpress  may  be  used.  For  some  unknown 
reason,  possibly  through  reflex  action,  the  taking  of  salt  on  the  back  of  the 
tongue  is  a  very  efficient  means  of  quickly  checking  the  hemorrhage. 

Gastric  Hemorrhage 

Gastric  hemorrhage  most  frequently  occurs  in  cases  of  ulcer.  The  patient 
should  be  kept  at  absolute  rest  with  an  ice  bag  over  the  stomach.  He  may 


UTERINE  HEMORRHAGE  „         225 

be  given  cracked  ice  to  swallow.  It  may  be  necessary  to  apply  a  large 
fomentation  over  the  lower  abdomen  or  to  other  parts  for  derivative  effects. 
The  cold  compress  is  not  as  efficient  as  the  ice  bag,  having  a  greater  tend- 
ency to  produce  a  hydrostatic  effect,  while  the  ice  bag  acts  chiefly  through 
reflex  action. 

Uterine  Hemorrhage 

We  may,  for  convenience,  divide  hemorrhages  from  the  uterus  into  two 
classes; — first,  prolonged  and  profuse  menses;  and  second,  hemorrhages  fol- 
lowing labor  or  abortion.  The  means  used  to  check  the  hemorrhage  in 
these  two  conditions  is  usually  quite  different,  since  one  is  acute  and  would 
soon  produce  exsanguination;  the  other  lasting  for  a  number  of  days  may  be 
treated  by  less  vigorous  means.  In  case  of  profuse  menses,  the  patient  may 
be  given  a  cold  sitz-bath.  This  should  be  prolonged  and  accompanied  by  a 
very  hot  foot  bath.  In  some  cases,  the  shallow  cold  foot  bath  (water  two  or 
three  inches  deep)  without  other  means  serves  to  check  the  hemorrhage. 
This  is  through  reflex  action.  In  case  it  is  necessary  to  keep  the  patient 
in  bed,  an  ice  bag  should  be  placed  over  the  pubes  and  another  ice  bag 
between  the  upper  surfaces  of  the  thighs.  At  the  same  time,  the  patient 
should  be  given  a  hot  foot  bath  or  leg  pack.  These  means  will  often  prove 
so  effectual  that  packing  or  astringent  douches  are  unnecessary. 

Post-partum  hemorrhage,  if  occurring  immediately  after  the  delivery  of 
the  child,  and  of  such  an  amount  as  to  prove  alarming,  should  be  immediately 
treated  by  a  very  hot  intra-uterine  douche.  If  the  hemorrhage  is  slight  or 
not  so  alarming  as  to  require  the  intra-uterine  douche,  the  patient  may  be 
given  a  very  hot  vaginal  douche  with  or  without  alum.  An  ice  bag  may  be 
used  over  the  pubes  and  replaced  after  the  douche, or  it  may  be  kept  in  place 
without  interruption.  Any  of  these  means  which  may  be  at  hand  should  be 
applied  at  once,  ergot  hyodermatically,  being  given  as  soon  as  possible. 

Apoplexy 

The  early  treatment  of  cerebral  hemorrhage  should  consist  of  an  ice  bag, 
ice  cap  or  large  ice  helmet  applied  to  the  head,  also  ice  bags  or  compresses 
placed  at  the  back  of  the  neck  and  over  the  carotids.  The  limbs  should  be 
kept  warm  by  hot  water  bottles,  etc.  These  applications  may  be  left  in 
place  until  there  is  reason  to  believe  the  hemorrhage  has  been  checked. 
Usually  the  hemorrhage  does  not  continue  for  any  great  length  of  time,  but 
in  some  cases  almost  the  entire  cerebrum  may  become  infiltrated  with  blood 
and  the  ventricles  filled.  Cold  applications,  if  used  promptly,  may  check 
such  excessive  hemorrhage  as  these.  Perfect  rest  is  an  absolute  essential 
to  the  success  of  any  form  of  treatment. 


CHAPTER    XXVII 
HYDROTHERAPY  IN  SURGERY 


Under  various  heads  we  have  already  considered  the  hydrotherapeutic 
treatment  of  many  surgical  diseases.  The  treatment  of  inflammatory  dis- 
eases, many  of  which  require  surgical  intervention,  has  been  discussed 
under  its  proper  head.  In  considering  the  effects  of  pure  stimulants  and 
under  treatment  designed  to  relieve  pain,  still  other  surgical  conditions  have 
been  discussed.  There  remains  then  to  be  considered  only  the  general  rela- 
tion of  hydrotherapy  to  operative  treatment  and  the  care  of  the  patient. 
For  convenience  the  subject  of  hydrotherapy  in  surgery  may  be  divided  into 
three  sections,  viz., — preparatory  treatment,  immediate  care  and  after-treat- 
ment. 

Preparatory  Treatment 

The  physical  condition  of  the  patient  at  the  time  of  operation  has  a  great 
deal  to  do  with  his  behavior  upon  the  operating  table  and  with  the  comfort 
and  rapidity  of  his  subsequent  convalesence.  Of  course  in  conditions 
demanding  immediate  attention  there  is  no  time  for  preliminary  treatment, 
but  in  a  very  large  number  of  surgical  diseases  it  is  neither  necessary  nor 
advisable  to  hurry  the  patient  to  the  operating  table.  This  is  true  alike  of 
many  inflammatory  and  many  non-inflammatory  conditions. 

In  considering  the  realm  of  physiologic  therapy  we  have  already  mentioned 
the  advisability  of  delay  in  the  operative  treatment  of  certain  inflammations, 
especially  of  pelvic  inflammations.  Even  definite  inflammatory  states  largely 
limited  to  the  Fallopian  tube  or  the  ovary  are  usually  accompanied  by  more 
or  less  cellulitis.  Sometimes  an  inflammation  whose  most  marked  effects 
are  in  the  cellular  tissue  involves  other  parts  so  as  to  necessitate  removal  of 
such  parts  or  mechanical  means  for  their  release  from  plastic  exudates  or 
adhesions.  In  such  cases  the  induration  and  residual  thickening  may  be 
cleared  up  and  quite  a  degree  of  the  normal  mobility  restored  as  has  been 
discussed  under  the  treatment  of  the  chronic  stage  of  inflammations.  These 
results  may  be  so  thoroughly  accomplished  that  the  remaining  conditions  will 
necessitate  very  much  less  operative  work  and  work  which  can  be  easily 
and  rapidly  performed  with  a  minimum  of  trauma  and  consequent  shock. 
The  resulting  shortening  of  the  peroid  of  anesthesia  is  also  a  distinct  advan- 
tage. 

The  stability  of  the  circulatory  system  is  still  another  factor  of  great 
importance  in  surgery.  In  those  who  have  had  chronic  inflammatory  or  sup- 
purative  lesions  and  in  neurasthenia  and  other  chronic  invalids  the  circula- 
tion is  unbalanced  and  the  vasomotors  fail  to  properly  control  the  ebb  and 


IMMEDIATE  CARE  227 

flow  of  circulatory  changes.  The  anesthetic  and  the  operative  procedure 
both  tend  to  still  further  unbalance  the  circulation.  By  interference  with  the 
vasomotors  the  liability  to  undue  cooling  of  the  surface  and  to  consequent 
internal  congestion  are  much  increased.  Slight  chilling  during  or  following 
operation  may  produce  marked  retrostasis  of  blood  to  the  interior,  and  thus 
result  in  deepening  an  already  existing  inflammation. 

The  preparation  of  the  patient  by  a  preliminary  two  or  three  weeks'  course 
of  vascular  hydriatic  tonics  will  guard  against  these  dangers.  In  this 
length  of  time  the  vitality  of  the  patient  may  be  materially  raised.  Such  a 
course  of  treatment  will  also  result  in  ridding  the  system  of  the  accumula- 
tion of  half  oxidized  leucomaines  which  have  piled  up  during  the  preceeding 
invalidism.  Sweating  treatments  at  intervals  of  two  or  three  days  may  also 
be  necessary  to  still  further  enhance  elimination  and  incidentally  to  pro- 
mote the  nutrition  and  healthy  activity  of  the  skin. 

The  stimulation  of  kidney  activity  and  the  consequent  increase  in  urinary 
leucomaines  is  another  factor  in  the  general  clearing  out  process.  Because 
of  the  more  perfect  oxidation  and  more  complete  elimination  of  waste  pro- 
ducts the  alkalinity  of  the  blood  is  increased.  Desirable  conditions  prepara- 
tory to  operation  are  also  produced  by  a  low  proteid  diet  and  the  free  use 
of  fruits.  Free  water  drinking  should  be  insisted  upon  whenever  the  elimi- 
nation is  defective.  All  of  these  changes  help  to  remove  toxemia — the 
principal  cause  of  nerve  irritation — and  hence  aid  in  rest  or  in  nerve  tone 
and  the  stability  of  nerve  action.  The  increased  activity  of  the  circulation 
and  the  restoration  of  the  normal  reaction  of  the  blood  and  body  fluids  are 
large  factors  in  the  proper  healing  of  wounds.  The  physiologic  leucocytosis 
and  consequently  heightened  phagocytic  powers  of  the  white  blood  cells  help 
to  prevent  post-operative  infections  whether  of  the  wound,  of  the  respira- 
tory tract  or  other  part  subject  to  unusual  conditions  or  strain  during 
operation. 

Immediate  Care 

The  treatment  of  the  patient  during  and  immediately  following  operation 
resolves  itself  almost  entirely  into  the  use  of  means  for  the  prevention  and 
treatment  of  surgical  shock  and  collapse.  The  keeping  of  all  the  vital  func- 
tions in  as  nearly  a  normal  condition  as  possible,  consistent  with  the  attain- 
ment of  surgical  anesthesia,  will  tend  to  prevent  the  occurrence  of  shock. 
The  use  of  ether  by  the  open  drop  method,  discarding,  unless  specially  indi- 
cated, all  mixing  of  anesthetics  or  the  hypodermic  use  of  hypotics  and 
analgesics,  has  done  much  to  lessen  the  occurrence  of  shock.  Let  the  ether 
be  given  slowly  at  the  start;  it  should  never  be  "pushed."  To  quite  an 
extent  this  will  obviate  the  occurrence  of  retching  and  vomiting.  Where 
the  alimentary  tract  is  not  the  objective  point  of  the  operation,  the  giving 
of  a  glass  of  cold  water  by  mouth,  immediately  before  beginning  the  admin- 
istration of  ether,  will  be  found  very  helpful  in  diminishing  the  tendency  to 
vomiting.  It  also  adds  that  much  water  to  the  body  fluids  to  aid  in  the  sub- 
sequent elimination  of  the  ether. 

The  skill  of  the  operator  in  proceeding  rapidly  yet  with  a  minimum  of 
trauma  and  hemorrhage  is  one  of  the  chief  factors  in  preventing  surgical 


228  HYDROTHERAPY  IN  SURGERY 

shock.  In  this  connection  W.  J.  Mayo1  has  said,  "We  hear  a  great  deal 
about  shock  but  we  don't  see  it.  We  sometimes  see  collapse  from  loss  of 
blood." 

The  patient  should  not  be  weakened  by  repeated  catharsis.  Limit  the 
preparatory  use  of  cathartics  to  what  is  really  indicated,  and  on  the  morning 
of  the  operation  finish  the  cleaning  out  by  means  of  a  thorough  enema  of 
tepid  or  warm  water.  The  patient  should  reach  the  operating  table  with 
warm  feet  and  hands  and  during  the  operation  the  extremities  should  be  kept 
warm  by  the  use  of  blanket  coverings  and,  if  necessary,  hot  water  bottles 
applied  outside  the  blanket.  The  use  of  a  hot  foot  bath,  concluded  by  a 
dash  of  cold  water,  given  just  before  entering  the  operating  room,  may  do 
much  to  prevent  or  limit  splanchnic  engorgement. 

Surgical  Shock 

Until  the  researches  of  Geo.  W.  Crile  placed  the  subject  of  the  causation 
of  surgical  shock  upon  a  definite  experimental  basis,  the  ideas  held  by  prac- 
ticing surgeons  were  most  various  and  conflicting  and  these  ideas  underwent 
frequent  change.  If  one  might  judge  of  these  ideas  by  the  therapy 
employed  at  that  time  and,  it  is  to  be  regretted  the  therapy  still  used  by  a 
very  large  number  of  surgeons,  one  would  unquestionably  say  that  some 
derangement  of  the  heart  itself  or  its  nerve  supply  has  been  looked  upon  as 
the  cause  of  surgical  shock.  That  the  heart  is  not  primarily  at  fault  in 
shock  has  been  proven  beyond  question. 

Crile  makes  a  sharp  distinction  between  shock  and  collapse.  Although 
there  are  many  contributing  causes,  he  considers  that  the  primary  and  prin- 
cipal alteration  of  function  in  surgical  shock  is  a  derangement  of  the  vaso- 
motor  mechanism.  Collapse  is  due  to  loss  of  body  fluid,  i.  e.,  to  hemorrhage. 
It  may  also  be  due  to  direct  damage  to  the  heart  muscle,  the  respiratory 
organs  or  the  nerves  of  either.  While  both  conditions  may  be  present  in  a 
given  case  at  the  same  time,  yet  they  are  essentially  distinct  entities.  These 
are  the  views  generally  accepted  by  surgeons  today. 

The  prevention  of  shock  is  fully  as  important  as  its  treatment,  and  to 
accomplish  either  result,  it  is  necessary  to  understand  the  causes  of  the  dis- 
ordered function.  We  may  therefore  with  profit  discuss  briefly  the  causes 
contributing  to  the  production  of  surgical  shock.  Crile2  enumerates  these 
under  approximately  six  heads.  These  are, — 

1.  Duration  of  operation. 

2.  Trauma. 

3.  Temperature. 

4.  Physical  condition  of  subject. 

5.  Anesthesia. 

6.  Hemorrhage. 

To  this  list  Yandell  Henderson3  has  recently  added  another  factor,  viz., — 
acapnia.  The  term  is  used  to  designate  a  state  in  which  there  is  a  deficiency 
of  carbon  dioxide  in  the  blood.  In  connection  with  these  seven  contributing 

1  Remarks  made  at  clinic  in  St.  Mary's  Hospital,  August  4,  1910. 

2  An  Experimental  Research  into  Surgical  Shock,  1899,  pp.,  135-144. 

3  American  Journal  of  Physiology. 


CAUSES  OF  SHOCK  229 

causes  we  should  also  discuss  the  vasomotor  and  the  cardiac  changes  pres- 
ent in  shock. 

1.  Duration  of  Operation.     The  duration  of  an  operation  always  bears  a 
direct  relation    to  the  occurrence  of  shock.      "In    all    the    experiments    in 
which  pure  shock  was  produced,  it  was  found  that  a  considerable  time  was 
required,  usually  half  an  hour  or  more."  4     With  ether  as  the  anesthetic,  it 
was  found  that  dogs  would  survive  its  continuous  administration  for  a  period 
of  time  averaging  ten  hours. 

2.  Trauma.     As  has  been  mentioned  trauma  is  one  of  the  chief  external 
causes  of    shock,  in    fact  the  term  "traumatic  shock"  is  frequently  used 
interchangeably  with    surgical    shock.     Trauma   of   nerve    centers,    nerve 
trunks  or  areas  richly  supplied  with  nerves,  is  especially  liable  to  produce 
shock.      Shock  is  also  especially  likely  to  occur  on  exposure  of  the  brain, 
pleura    and    peritoneum.       "Exposure  of   the    capacious  splanchnic  area  is 
attended  by  a  rapid  dilatation  of  the  splanchnic  vessels,  leading  to  intense 
congestion,  detracting    thereby    a   dangerous    amount   of    blood    from  the 
somatic  circulation,  and  inducing  a  rapidly  declining  blood  pressure." 

3.  Temperature.     '  'Contact  with  air  is  a  very  great  irritant  to  local  tissues, 
owing  to  the  lowering  of  local  temperature  and  to  the  drying."      Animals 
operated  in  a  cold  room  seem  to  succumb  more  readily  than  under  ordinary 
warmth.     The  depressing  effects  of  cold  were  plainly  seen  when  cold  water 
was  brought  in  contact  with  the  intestines  or  when  an  intra-venous  injection 
of  cold  saline  solution  was  given.      The  effects  of  warm  towels  applied  to 
the  exposed  intestines  or  of  warm  saline  solution  in  the  abdomen  immedi- 
ately improved  the  respiration  and  checked  declining  blood  pressure.      The 
same  effect  of  cold  and  warm  salines  was  noticed  on  the  brain  and  exposed 
nerve  fibers. 

4.  Physical  Condition.     Individuals  in  impaired  health,  poorly  nourished, 
with  sluggish  circulation,  too  young  or  too  old,  are  always  bad  subjects  for 
operation.     We  have  elsewhere  mentioned  various  physical  conditions  which 
contribute  to  the  occurrence  of  shock. 

5.  Anesthesia.     Over-anesthesia,  rapid  anesthesia  at  the  start,  or  awk- 
ward or  irregular  giving  of  an  anesthetic,  contribute  to  the  production  of 
shock.      Chloroform  requires  much  greater  care  in  its  administration  than 
ether.     Chloroform  is  more  toxic  than  ether.     Chloroform  may  cause  sudden 
caidiac  arrest;  and  if  this  occurs,  it  is  usually  before  surgical  anesthesia  is 
attained.      In  this    respect    clinical  experience  coincides  with  experiment. 
For  these  reasons,  in  America,  the  majority  of  surgeons  prefer  ether,  using 
it  almost  exclusively. 

6.  Hemorrhage.      Loss  of  blood  always  predisposes  to  the  occurrence  of 
shock.      Hemorrhage    from    veins  is  productive  of  more    immediate    harm 
than  hemorrhage  from  arteries.       "Hemorrhage  from  large  venous  trunks 
caused  the  most  profound  effect  upon  the"b'lood  pressure,  because  the  quan- 
tity of  blood  supplied  to  the  heart  was  immediately  diminished,  while  if  the 
hemorrhage  was  arterial,  the  income  of  blood  was  not  so  suddenly  diminished. 
The  output  of  the  heart  does  not  depend  at  all  upon  the  height  of  the  arte- 
rial pressure,  but  is  in  direct  proportion  to  the  venous  pressure." 

4    Crile— Blood  Pressure  in  Surgery,  1903,  p.  298. 


230  HYDROTHERAPY  IN  SURGERY 

7.  Acapnia.  Henderson  holds  that  carbon  dioxide  is  a  harmone,  or  chemi- 
cal regulator,  of  respiration  and  that  the  phenomena  of  vasomotor  failure 
in  shock  are  due  to  diminution  of  this  gas  in  the  blood  and  body  tissues. 
This,  he  claims,  is  brought  about  by  the  excessive  respiration  (and  conse- 
quent over-ventilation  of  the  blood)  caused  by  excitement,  fear,  pain  or 
forced  breathing.  Anesthetics  tend  to  prevent  shock  because  they  dimin- 
ish the  excessive  respiration  due  to  pain.  The  habit  of  covering  the  face 
and  ether  mask  with  extra  layers  of  gauze,  thus  causing  the  patient  to 
rebreathe  some  of  his  own  carbon  dioxide,  is  pointed  out  in  support  of  this 
theory;  it  being  believed  that  this  practice  helps  to  maintain  more  perfect 
narcosis  and  raise  the  blood  content  of  carbon  dioxide.  Henderson  states 
that  "skillful  anesthesia  consists  in  maintaining  the  threshold  of  the  respira- 
tory center  for  carbon  dioxide  at  a  nearly  normal  level,  and  in  avoiding  the 
development  of  either  acapnia  or  hypercapnia. "  The  theory  seems  to  have 
many  points  in  its  favor;  it  needs  further  confirmation. 

Vasomotor  Changes.  The  experimental  data  upon  which  the  vasomotor 
theory  of  traumatic  shock  rests  is  altogether  too  lengthy  to  be  given  here, 
even  in  abstract.  It  has,  however,  been  shown  that  in  surgical  shock  the 
changes  in  blood  pressure  are  entirely  independent  of  the  working  power  of 
the  heart  itself.  In  an  animal  reduced  to  a  state  of  shock,  the  heart  con- 
tinues to  beat  with  its  usual  force  as  long  as  it  is  supplied  with  the  normal 
amount  of  blood,  i.  e.,  as  long  as  it  is  furnished  with  something  upon  which 
to  expend  its  force. 

In  shock  the  vasomotors  are  at  first  over  excited  and  reveal  symptoms  of 
irregular,  disordered  action.  Vasomotor  curves  of  blood  pressure  (Traube- 
Hering  curves)  become  rhythmic  over  a  large  area  and  are  exaggerated. 
Later,  after  some  exhaustion  has  set  in,  vasomotor  effects  are  more  diffi- 
cult to  produce.  Rhythmic  variations  finally  cease  and  changes  in  vascular 
calibre  end  in  maximal  vasodilatation.  In  animal  experiments,  after  removal 
of  the  stellate  ganglia,  stimulation  produced  neither  a  rise  nor  a  fall.  In 
drawing  conclusions  from  these  phenomena,  Crile  says,  "These  several 
results,  so  many  times  obtained,  are  taken  as  evidence  of  a  vasoconstrictor 
mechanism  or  action  and  a  vasodilator  mechanism  or  action,  or,  in  other 
words,  a  pressor  and  a  depressor  action,  and  that  the  former  is  exhausted 
more  readily  than  the  latter." 

"In  a  number  of  vasomotor  phenomena  observed,  it  was  apparent  that 
there  are  regional  vasomotor  actions  quite  independent  of  each  other." 

"There  is  no  portion  of  the  circulatory  apparatus  so  delicate,  whose  equi- 
librium is  so  easily  disturbed,  and  whose  connection  with  all  the  parts  of 
the  body  is  so  minute  as  the  vasomotor.  A  priori,  it  would  be  the  most 
readily  disturbed  as  well  as  the  most  readily  exhausted  and  to  such  conclu- 
sions do  our  observations  lead  us.  The  more  richly  supplied  with  vasomotor 
nerves  was  a  given  area,  the  rrtore  rapidly  was  the  vasomotor  mechanism 
exhausted  when  such  area  was  subjected  to  injury.  This  principle  was 
abundantly  illustrated  in  the  experiments  upon  the  splanchnic  area." 

"The  experiments  of  Mall  show  that  the  splanchnic  nerves  are  vein-nerves 
and  control  this  large  and  spacious  vascular  area.  Every  experiment  in 
this  area  gave  evidence  of  the  dilatation  of  the  vessels  controlled  by  these 


CHANGES  IN  SHOCK  231 

nerves,  and  the  decline  of  the  pressure  occurred  pari  passu  with  this  dila- 
tation." 

Cardiac  Changes.  It  is  perfectly  evident  as  remarked  by  Crile  that,  "The 
heart  is  the  base  of  support  of  the  blood  pressure,  and  any  interference 
with  its  action  at  once  causes  marked  changes  in  the  pressure."  The  heart 
action  is  thus  directly  influenced  by  venous  pressure  in  the  vena  cava.  Hen- 
derson places  special  emphasis  upon  this  latter  factor  in  discussing  what  he 
has  called  the  "veno-pressor"  mechanism.  The  recognition  of  this  factor 
in  cardiac  action  is,  however,  not  new.  It  was  early  pointed  out  by  Crile 
in  his  researches  into  the  causes  of  altered  heart  action  (and  lowered  blood 
pressure)  in  shock.  He  says,  "The  output  of  the  heart  is  in  direct  ratio  to 
the  pressure  of  the  vena  cava,  and  not  at  all  to  the  height  of  the  aortic 
blood  pressure.  The  venous  pressure,  then,  determines  the  heart's  output 
and  the  venous  pressure  is,  in  a  good  measure,  dependent  upon  the  force 
and  frequency  of  the  heart-beats,  together  with  the  necessary  vascular  tone, 
which  is  under  the  control  of  the  vasomotor  nerves." 

Through  vasomotor  exhaustion  the  blood  accumulates  in  the  dilated  veins, 
especially  those  of  the  splanchnic  area  which  are  so  capacious.  There  has 
therefore  occurred  "a  hemorrhage  into  the  veins."  This  is  due  both  to 
exhaustion  of  the  vasomotors  of  the  veins  with  consequent  vasodilatation 
and  to  the  failure  of  the  arterioles  to  continue  their  pumping  action.  This 
latter  is  likewise  a  result  of  vasomotor  failure.  The  results  of  vein  engorge- 
ment may  be  temporarily  overcome  by  pressure  upon  the  abdomen  or  by  the 
use  of  the  pneumatic  suit  devised  by  Crile. 

Pumping  Action  of  the  Blood  Vessels.  The  control  or  maintenance  of  a 
definite  vascular  calibre  is  not  the  only  work  of  the  vasomotors;  vascular 
activity  is  also  controlled  by  the  vasomotor  centers.  Arterial  vascular 
activity  helps  to  fill  the  veins  and  venous  vascular  activity  helps  to  maintain 
blood  pressure  in  the  vena  cava.  While  laying  great  stress  upon  vascular 
calibre  in  its  effects  upon  the  work  of  the  heart,  nearly  all  observers  entirely 
ignore  vascular  activity.  To  illustrate  the  three  factors  in  the  circulation, 
Henderson fl  employs  a  diagram  in  which  the  arteries  are  represented  by  rigid 
tubes  and  changes  in  their  calibre  as  equivalent  to  the  widening  or  narrow- 
ing of  nozzle  outlets.  While  this  may  illustrate  one  factor  in  the  work  of  the 
vasomotors,  it  entirely  overlooks  arterial  activity,  the  result  of  which  it  is 
impossible  to  conceive  of  as  illustrated  by  mere  changes  in  resistance,  brought 
about  by  the  widening  or  narrowing  of  the  nozzles. 

In  conclusion  it  must  therefore  be  admitted  that  failure  of  the  vasomotor 
mechanism  is  the  chief  immediate  cause  of  surgical  shock.  Neither  the 
views  of  Porter  and  Quinby,  Seelig  and  Lyon,  or  Yandell  Henderson  have 
greatly  altered  this  conception  of  the  pathologic  physiology  of  shock. 

The  Treatment  of  Shock 

There  is  no  better  place  than  the  operating  room  in  which  to  demonstrate 
the  prompt,  tangible  results  obtained  by  the  use  of  hydrotherapeutic  stimu- 
lation. In  operations  upon  the  head,  in  prolonged  or  extensive  abdominal 
operations,  breast  amputations,  etc.,  and  in  other  cases  where  shock  is  likely 

5    American  Journal  of  Physiology,  Vol.  XXVII,  No.  1,  p.  159. 


232  HYDROTHERAPY  IN  SURGERY 

to  appear  and  prove  dangerous,  the  success  attained  by  the  use  of  hydro- 
therapy  has,  in  our  hands,  been  uniformly  gratifying.  This  has  also  been  the 
experience  of  many  others  working  in  the  association  of  medical  institutions 
with  which  the  writer  is  connected. 

The  plan  which  we  have  followed  is  very  similar  to  that  outlined  in  Chap- 
ter XX  for  the  relief  of  acute  edema  of  the  lungs  and  circulatory  crisis  in 
valvular  heart  disease.  There  are  certain  additional  features  to  be  taken 
into  account  so  that  it  will  be  repeated  here  in  full.  The  principles  involved 
in  the  hydrotherapeutic  treatment  of  surgical  shock  are  neither  complicated 
nor  difficult  to  understand.  Their  intelligent  effective  application,  however, 
requires  a  knowledge  of  the  causation  and  morbid  physiology  of  shock,  a 
thorough  acquaintance  with  the  methods  used,  and  an  experience  in  their 
use  in  order  to  know  how  to  adapt  the  means  to  the  case  in  hand  and  bring 
results  where  these  results  are  difficult  to  obtain. 

The  vasomotor  failure  in  surgical  shock  can  be  and  is  met  ideally  by  only 
one  method  of  procedure,  viz,— the  application  of  cold  water  combined  with 
friction.  If  hemorrhage  has  occurred,  the  loss  of  fluid  must  be  met  by  the 
introduction  of  more  fluid.  Warm  saline  solution  may  be  given  by  hypoder- 
moclysis  or  by  proctoclysis  according  to  the  urgency  of  the  case.  It  is  usually 
well  to  give  the  hypodermoclysis  while  the  patient  is  on  the  operating  table 
and  follow  it  with  saline  solution  by  either  intermittant  protoclysis  or  by 
continuous  proctoclysis  after  the  method  of  Murphy,  begun  as  soon  as  the 
patient  reaches  his  room. 

When  shock  appears  during  the  operation  the  patient  should  be  treated 
on  the  operating  table.  The  effectual  treatment  of  shock  requires  the  atten- 
tion of  two  persons.  On  the  appearance  of  the  symptoms  of  shock,  immed- 
iately place  the  patient's  feet  in  hot  water,  care  being  taken  that  the  water 
is  not  nearly  hot  enough  to  produce  a  burn;  or  quickly  apply  well  wrapped 
fomentations  so  as  to  cover  both  feet  and  legs  to  the  knees.  As  soon  as  the 
parts  have  been  well -warmed  and  reddened,  remove  the  hot  applications 
and  quickly  administer  to  the  same  parts  a  cold  mitten  friction.  The  water 
used  should  be  ice  water  and  the  friction  most  vigorously  given.  The  mitts 
should  be  dipped  2  or  even  3  times,  another  attendant  holding  the  limb  while 
it  is  being  treated.  The  skin  is  now  dried  and  rubbed  with  a  coarse  Turkish 
towel  and  immediately  covered  with  a  warm  dry  blanket.  The  thighs  should 
be  treated  in  the  same  manner,  also  the  arms.  While  this  is  being  done 
and  beginning  at  the  same  time  as  the  first  treatment  to  the  limbs,  intense 
and  quickly  alternating  hot  and  cold  applications  should  be  made  to  the 
anterior  surface  of  the  chest  and  especially  over  the  precordia.  This  may 
be  done  by  removing  the  ice  bag  from  the  precordia,  which  should  have  been 
placed  there  when  the  pulse  first  became  unduly  rapid,  and  after  rubbing 
the  skin  briskly,  applying  a  very  hot  but  well  covered  fomentation.  This 
should  not  be  left  in  contact  with  the  skin  longer  than  15  or  30  seconds. 
Next,  rub  the  chest  with  a  flat  smooth  piece  of  ice,  using  quick  to-and-fro 
movements  and  wiping  away  the  water  with  a  Turkish  towel.  After  this 
another  fomentation  is  applied,  again  followed  by  the  ice.  These  alterna- 
tions should  be  repeated  3  or  4  times,  after  which  the  well  covered  ice  bag 
should  again  be  placed  over  the  heart. 

Wherever  there  is  any  hope  at  all  of  vasomotor  response,  these  measures 


TREATMENT  OF  SHOCK  233 

result  in  prompt  rise  of  blood  pressure  and  as  prompt  cardiac  response  to 
the  increased  venopressure.  Where  an  abdominal  operation  is  being  done, 
it  is,  perhaps,  needless  to  say  that  warm  gauze  napkins  should  be  applied 
and,  if  feasible,  some  pressure  exerted  upon  the  splanchnic  area  in  order 
to  more  quickly  send  the  blood  on  to  the  heart.  Rather  than  leave  fluid  in 
the  abdomen,  we  prefer  to  give  warm  saline  solution  per  rectum  even  while 
the  patient  is  still  on  the  operating  table. 

Unless  the  shock  is  very  severe  it  will  not  be  necessary  to  repeat  the 
vasomotor  stimulation  short  of  thirty  or  forty  minutes.  If  the  condition  of 
the  patient  permits  and  repetition  of  the  vigorous  measures  outlined  above 
is  not  really  needed,  it  will  be  better  from  now  on  to  employ  milder  tonics 
after  giving  some  efficient  derivative  treatment. 

The  principle  of  this  plan  of  treating  shock  lies  in  the  effect  of  brief  appli- 
cations of  heat  to  the  skin  surface  and  especially  to  the  limbs,  in  order  to 
warm  the  skin  and  aid  in  reducing  internal  congestion.  The  quickly  follow- 
ing cold  friction  produces  vigorous  stimulation  of  the  vasomotors,  so  that 
the  blood  pressure  rises  immediately.  The  vascular  condition  is  not  at  all 
comparable  with  that  produced  by  the  injection  of  adrenalin.  It  is  not  a 
stationary  vasoconstriction  that  results  from  a  cold  friction,  but  a  vascular 
activity — a  rapidly  alternating  dilatation  and  contraction  of  the  blood  ves- 
sels. This  is  a  true  pumping  action  which  is  in  reality  only  a  heightening 
of  the  normal  activity  of  the  blood  vessels. 

The  effect  of  different  temperatures  upon  blood  pressure  has  already  been 
discussed  in  Chapter  IX,  where  the  laws  deduced  by  Muller  are  recorded. 
Muller's  studies  into  the  effects  of  baths  on  blood  pressure  were  carried 
out  by  means  of  a  Riva-Rocci  instrument  and  were  very  carefully  done  with 
apparently  every  precaution  taken.  Those  who  desire  to  study  further  these 
experiments  will  find  a  complete  consideration  of  the  question  given  in  his 
paper.  6 

In  meeting  Henderson's  acapnia,  what  could  be  more  ideal  than  raising 
the  carbon  dioxide  content  of  the  blood  and  tissues  by  stimulating  its  pro- 
duction from  the  tissues  themselves  through  increased  oxidation?  That 
this  can  be  efficiently  done  by  thermic  and  mechanical  stimuli  and  results 
very  promptly  from  the  application  of  such  means,  has  already  been  shown 
in  Chapter  XII.  The  circulatory  stimulation  and  the  stimulation  of  respira- 
tion by  the  same  means  serve  to  maintain  the  proper  per  cent  and  proportion 
of  oxygen  and  carbon  dioxide  in  the  blood. 

In  concluding  the  consideration  of  the  treatment  of  surgical  shock,  other 
than  a  practical  experience  in  the  satisfactory  results  attained,  we  could 
offer  no  better  apology  for  the  presentation  of  so  simple  a  plan  for  its  treat- 
ment than  to  summarize  the  experimental  work  and  conclusions  therefrom, 
reached  by  recognized  authorities,  showing  the  failure  of  older  and  more 
pretentious  methods.  Those  who  wish  the  facts  at  first  hand  will  find  the 
results  of  the  most  exhaustive  and  conclusive  studies  along  this  line  given 
by  Dr.  Crile  in  his  monumental  work,  "Blood  Pressure  in  Surgery, ""  which 
appeared  in  1903. 

6  Uber  den  Einfluss  von  Badern  und  Douchen  auf  den  Blutdruck  beim  Menschen — Deut.  Arch, 
fur.  klin.  Med.,  1902,  volume  LXX1V,  p.  316. 

7  Quotations  immediately  following-,  unless  otherwise  credited,  are  from  this  work,  pp.  261 
to  300. 


234  HYDROTHERAPY  IN  SURGERY 

Alcohol.  "The  immediate  effect  of  intravenous' administration  only  was 
observed.  The  first  effect  usually  noticed  was  a  decline  in  the  blood  pressure. 
In  the  majority  of  such  instances  a  compensatory  rise  followed;  in  a  number 
of  instances  no  change  in  the  blood  pressure  was  noted;  in  but  few  was 
there  a  rise.  The  average  length  of  the  stroke  of  the  manometer  (height 
of  pulse  wave)  was  increased.  There  was  no  evidence  that  the  heart  beat 
more  forcibly.  In  animals  reduced  to  varying  degrees  of  surgical  shock, 
the  usual  effect  of  an  average  dose  of  alcohol  was  the  production  of  a  fur- 
ther depression;  in  smaller  doses  but  little  effect  was  noted,  while  in  larger 
doses  a  more  marked  decline  often  occurred.  In  few  instances  the  administra- 
tion of  a  considerable  dose  in  deep  shock  was  followed  by  almost  immediate 
death.  In  a  number  of  experiments  the  decline  in  the  blood  pressure  was 
as  prompt  and  as  marked  as  in  the  administration  of  the  amyl  nitrite  and 
nitroglycerin.  In  no  instance,  in  the  normal  animal,  did  death  immediately 
follow  the  largest  dose  of  alcohol;  the  more  profound  the  shock,  the  more 
marked  was  the  depressing  effect  of  alcohol.  In  a  number  of  experiments 
alcohol  was  given  prior  to  procedures  intended  to  produce  shock.  It  is  not 
certain  that  it  rendered  the  animal  more  susceptible.  It  is  quite  certain 
that  the  susceptibility  was  not  diminished." 

Nitroglycerin  and  Amyl  Nitrite.  "The  immediate  effect  of  nitroglycerin 
and  amyl  nitrite  upon  the  pulse  was  an  increase  in  its  volume  and  a  decrease 
in  frequency.  The  immediate  effect  upon  the  respiration  varied.  At  times 
there  was  a  slight  increase,  more  frequently  a  slowing  of  respiration.  The 
immediate  effect  upon  the  blood  pressure  in  almost  every  instance  was  a  fall. 
The  decline  was  usually  rapid.  There  were  but  few  exceptions,  and  in  these 
there  was  usually  no  effect.  A  rise  was  rarely  observed.  In  the  latter 
it  was  but  temporary  and  was  usually  followed  by  a  fall.  The  descent  in 
the  blood  pressure  was  gradual  and  rather  rapid,  the  ascent,  more  gradual. " 

"In  the  experiments  in  which  the  animal  was  in  deep  shock,  and  the  blood 
pressure  was  gradually  falling,  there  was  no  evidence  to  show  any  decrease 
in  the  rapidity  of  the  decline.  On  the  contrary,  as  nearly  as  could  be  esti- 
mated, nitroglycerin  distinctly  increased  the  rapidity  of  the  decline.  The 
effect  of  nitrite  of  amyl  was  in  every  respect  similar  to  that  of  nitroglycerin. 
In  many  instances  the  heart  beat  irregularly  after  the  injection.  On  the 
whole,  nitroglycerin  and  amyl  nitrite  increased  shock." 

Digitalis.  The  administration  of  digitalis  in  the  normal  animal  produces 
a  rise  of  blood  pressure  which  is  well  sustained.  The  drag  is  very  likely  to 
cause  over-stimulation  resulting  in  sudden  cardiac  failure.  In  varying 
degrees  of  shock,  digitalis  produces  a  less  marked  rise  of  blood  pressure 
than  in  the  normal  animal.  "The  respiration  when  at  all  affected  was  either 
impaired  or  arrested.  Death  in  the  digitalis  experiments,  even  in  those  in 
which  the  dosage  was  only  therapeutic,  was  usually  more  sudden  than  in  the 
controls.  Although  the  data  does  not  permit  positive  statements,  it  seemed 
on  the  average,  that  cases  of  shock  treated  by  digitalis  did  not  live  as  long 
as  the  controls.  It  may  certainly  be  stated  that  they  did  not  live  longer 
than  the  controls." 

Strychnin.  "In  the  majority  of  instances,  in  the  normal  animal,  when 
sufficient  amount  of  strychnin  was  given  to  cause  an  increased  excitability 
of  the  spinal  cord,  as  indicated  by  heightened  reflexes  and  an  increased 


STRYCHNIN  IN  SHOCK  285 

muscular  tone,  a  rise  in  blood  pressure  was  noted.  In  smaller  doses,  occas- 
ionally, a  slight  immediate  fall,  a  slight  immediate  rise,  or  later  irregularities 
were  noted,  but  on  making  48  careful  measurements  of  the  effects,  it  was 
found  that  no  noteworthy  changes  occurred." 

"In  48  experiments,  it  was  found  that  strychnin  in  therapeutic  doses  does 
not  cause  a  rise  in  blood  pressure."8 

"The  stage  of  increased  excitability  above  mentioned,  represented  the 
border-land  between  the  dosage  without  effect  upon  the  blood  pressure  and 
that  of  maximum  effect.  When  more  was  given  after  this  stage  had  been 
reached,  convulsions  appeared,  and  the  blood  pressure  rose  abruptly,  and 
high,  sometimes  even  more  than  doubling  the  normal.  The  curve  during 
the  convulsions  was  exceedingly  irregular,  and  continued  for  some  time 
above  the  normal,  exhibiting  a  secondary  rise  if  later  convulsions  occurred. " 
In  speaking  of  strychnin  experiments  in  which  both  vagi  and  accelerantes 
were  severed  and  curare  given,  Doctor  Crile  says,  "On  repeating  the  dose 
a  period  was  soon  reached  in  which  no  further  effect  was  noted.  After  each 
dose,  when  the  effect  had  worn  off,  the  blood  pressure  fell  to  a  lower  level 
than  it  was  before  the  injection  was  given,  until  finally  it  reached  the  level, 
usually  between  20  and  30  mm.  which  was  not  altered  by  an  additional 
dosage. ' ' 

"In  a  series  of  experiments  in  which  strychnin  was  given  in  various 
degrees  of  shock  in  such  dosage  as  to  cause  a  stimulation,  the  effect  was 
proportional  to  the  degree  of  shock,  i.  e.,  when  but  little  shock  was  present, 
a  marked  effect  from  strychnin  was  obtained;  and  when  most  profound,  there 
was  no  effect.  In  the  intervening  degrees,  the  effects  were  proportional, 
but  after  giving  the  strychnin,  the  animals  not  yet  incomplete  shock  always 
passed  into  a  deeper  degree  of  shock.  In  any  degree  of  shock,  after  the 
administration  of  a  therapeutic  dose  of  strychnin,  the  animals  passed  into 
deeper  shock.  Later  in  the  research,  it  was  found  that  the  most  convenient 
and  certain  method  of  producing  shock  for  experimental  purposes,  is  by  the 
administration  of  physiologic  doses  of  strychnin.  The  treatment  of  shock, 
then  by  therapeutic  doses  of  strychnin  is  inert  and  physiologic  doses  danger- 
ous. 

"It  then  follows  that  treatment  of  shock  by  vasomotor  stimulants  in  the 
form  of  drugs,  is  on  precisely  the  same  basis  as  treatment  by  burning  the 
animal  or  crushing  his  paws,  or  by  subjecting  it  to  injury  or  operation, 
it  would  seem  to  be  as  reasonable  to  treat  strychnin  shock  by  administering 
traumatism  as  traumatism  by  strychnin."910 

"Surgical  shock  is  an  exhaustion  of  the  vasomotor  center.  Neither  the 
heart  muscle,  nor  the  cardio-inhibitory  center,  nor  the  cardio-accelerator 
center,  nor  the  respiratory  center,  are  other  than  secondarily  involved.  Col- 
lapse is  due  to  a  suspension  of  the  function  of  the  cardiac  or  of  the  vasomotor 
mechanism.  In  shock  therapeutic  doses  of  strychnin  are  inert,  physiologic 
doses  dangerous  or  fatal.  If  not  fatal,  increased  exhaustion  follows.  There 
is  no  practical  distinction  to  be  made  between  external  stimulation  of  this 

8  Crile— Detroit  Medical  Journal,  May,  1903,  p.  38. 

9  Ibid,  pp,  38  and  39. 

10  Doctor  Crile  shows  sections  of  brain  tissue  revealing  degeneration  of  the  Purkinje  cells 
from  continuous  use  of  strychnin. 


236  HYDROTHERAPY  IN  SURGERY 

center  as  in  injuries  and  operation,  and  internal  stimulation  by  vasomotor 
stimulants,  as  by  strychnin.  Each  in  sufficient  amount  produces  shock;  and 
each,  with  equal  logic,  might  be  used  to  treat  the  shock  produced  by  the 
other.  Stimulants  of  the  vasomotor  center  are  contraindicated.  Cardiac 
stimulants  have  but  a  slight  range  of  possible  usefulness,  and  may  be 
injurious.  .  .  .  Adrenalin  acts  upon  the  heart  and  blood  vessels.  It 
raises  the  blood  pressure  in  the  normal  animal;  in  every  degree  of  shock; 
when  the  medulla  is  cocainized;  and  in  the  decapitated  animal.  It  is  rapidly 
oxidized  by  the  solid  tissues  and  the  blood.  Its  effects  are  fleeting;  it  should 
be  given  continuously."11  The  effect  of  a  single  dose  of  adrenalin  lasts 
from  two  to  four  minutes.  "The  longest  time  that  the  action  of  the  extract 
on  the  blood  pressure  was  prolonged  was  found  to  be  four  minutes. 
With  the  continuous  flow  of  the  extract  into  the  vein,  however,  the  pres- 
sure was  kept  up  as  long  as  the  flow  was  continued,  and  for  the  usual  time 
after  it  had  been  discontinued." 

After-Treatment 

Post-anesthetic  Infections.  The  question  of  how  best  to  prevent  and 
treat  post-anesthetic  pneumonia,  wound  infections,  and  other  infections 
following  operations  is  an  ever  present  one,  and  to  the  surgeon  the  cause 
of  no  little  anxiety  during  the  first  3  or  4  days  of  the  after-care  of  the  patient. 

Modern  aseptic  technic  together  with  caution  in  regard  to  unnecessary 
traumatism  in  operating  and  in  regard  to  injury  of  the  tissues  by  strong 
antiseptics  or  the  prolonged  application  of  antiseptics,  also  the  proper  use 
of  serum  drainage,  has  reduced  wound  infection  very  largely  to  a  matter 
of  the  resistance  of  the  patient's  tissues. 

We  have  already  shown  how  the  tissue  resistance  may  be  increased  by 
preparatory  treatment.  There  is,  however,  one  cause  of  lowering  of  the 
vital  resistance  which,  in  the  nature  of  the  case,  can  not  be  eliminated.  This 
factor  in  lowering  resistance  is  nothing  else  than  the  anesthetic  itself.  It 
results  in  limiting  or  checking  for  the  time  being,  both  phagocytosis  and 
leucocytic  activity. 

After  anesthesia,  the  power  of  the  blood  to  destroy  pathogenic  bacteria 
is  markely  reduced.  "In  fact,  the  members  of  the  entire  group  of  alcohol, 
ether  and  chloroform  reduce  the  power  of  the  blood  to  combat  bacteria;  the 
state  of  a  man  after  a  long  anesthesia  is  comparable  to  that  of  an  alcoholic 
with  bronchitis  who  has  been  sleeping  off  an  overdose  of  alcohol  in  a  door- 
way or  a  freight  car. 

'  'So  important  a  subject  is  this  post-operative  pneumonia  that  much  interest 
attaches  to  the  recent  studies  of  Graham  on  anesthesia  and  the  bactericida 
powers  of  the  blood.  According  to  these  experiments,  it  is  not  the  power 
which  serum  itself  has  of  destroying  bacteria  through  bacteriolysis  which 
is  reduced  by  anesthetics,  but  the  destruction  of  bacteria  by  phagocytosis 
is  greately  reduced.  Now  it  so  happens  that  the  organisms  which  we  have 
to  fear  in  surgery,  the  pneumococcus  aud  the  pus  cocci,  are  destroyed  chiefly 
through  phagocytosis  and  not  by  bacteriolysis,  which  gives  added  importance 
to  this  depressing  effect  on  the  bactericidal  powers  of  the  blood.  Appar- 

11     Ibid.,  p.  45. 


AFTER-TREATMENT  237 

ently  ether,  the  anesthetic  which  Graham  has  studied,  reduces  both  the  effic- 
iency of  the  opsonins  and  the  power  of  the  leucocytes  to  take  up  the  sensitized 
bacteria;  these  effects  can  be  seen  both  in  the  blood  of  the  patients  or 
animals  after  anesthesia,  and  in  drawn  normal  blood  treated  with  ether  in 
the  test  tube.  The  action  of  the  ether  is  not  permanent,  the  opsonic  power 
being  restored  promptly  on  removal  of  the  ether."  M 

Dr.  C.  Achard  has  recently  called  attention  to  these  facts  and  their  impor- 
tance in  the  causation  of  certain  post-operative  accidents,  in  a  paper  read 
before  the  Academie  de  Medecine.  13 

The  use  of  morphin  as  an  anesthetic  aid,  even  where  definitely  indicated, 
must  of  necessity  be  an  added  source  of  danger  from  infections.  L.  Rey- 
nolds H  has  emphasized  this  fact  and  called  attention  to  the  disadvantage  in 
using  morphin. 

"From  experiments  performed  by  him,  Reynolds  concludes  that  morphin 
exerts  a  marked  influence  on  the  leucocytes.  Not  only  does  it  check  diape- 
desis,  but  phagocytosis  is  diminished  in  a  marked  degree.  The  growth  of 
bacteria,  on  the  other  hand,  is  not  appreciably  affected.  What  bearing  has 
this  on  the  practice  of  medicine  and  surgery?  It  is  probable  that  in  most 
surgical  operations  a  certain  number  of  pathogenic  organisms  gain  entrance 
to  the  wound,  however  carefully  asepsis  be  observed.  The  further  history 
of  the  case  turns  on  this  point.  Will  the  phagocytes  be  able  to  destroy  these 
bacteria  before  the  latter  have  multiplied  sufficiently  to  gain  the  upper 
hand?  If  morphin  temporarily  paralyzes  the  activity  of  the  phagocytes,  if 
this  drug  be  given,  time  is  lost  during  which  the  bacteria  multiply.  When 
the  narcosis  passes  off,  the  phagocytes  may  be  unable  to  destroy  the  bacteria 
on  account  of  their  number  and  the  paralyzing  effect  of  the  toxins  produced 
by  them;  in  fact  by  giving  the  morphin  the  chances  of  sepsis  have  been 
increased."  15 

It  thus  appears  plain  that  the  use  of  mixed  anesthesia  is  not  to  be  en- 
couraged unless  very  definitely  indicated.  The  use  of  morphin  may  be 
necessary  in  operations  for  hyperthyroidism  and  in  a  few  other  conditions, 
but  unless  there  are  good  reasons  for  its  administration  in  other  conditions, 
it  should  not  be  given. 

In  the  treatment  and  prevention  of  post-anesthetic  infections,  there  are 
three  things  to  be  accomplished.  These  are,— first,  the  rapid  elimination  of 
the  ether;  second,  the  raising  of  the  leucocytic  activity;  and  third,  the  reduc- 
tion of  local  congestions. 

Rapid  elimination  of  ether  is  best  accomplished  by  the  giving  of  much 
water  immediately  following  the  operation.  The  use  of  the  saline  enema  is 
specially  helpful.  In  giving  continuous  proctoclysis,  after  the  volume  of 
the  circulating  fluid  has  reached  normal,  the  added  fluid  is  eliminated  by  the 
kidneys  as  fast  as  it  is  absorbed. 

This  same  measure  also  helps  in  decreasing  the  danger  from  post-operative 
nephritis.  As  soon  as  the  patient  is  out  from  under  the  anesthetic,  copious 
water  drinking  should  be  insisted  upon.  It  will  not  be  likely  to  cause  vomit- 

12  Editorial  in  Journal  of  American  Medical  Association,  Feb.  18,  1911. 

13  April,  1910. 

14  London  Lancet,  Feb.  26,  1910. 

15  Abstract  of  article  by  Reynolds  in  Journal  of  American  Medical  Association. 


238  HYDROTHERAPY  IN  SURGERY 

ing,  and  if  it  should  seem  to  have  this  effect,  gastric  lavage  may  be  resorted 
to  and  continued  until  the  stomach  has  been  washed  clean.  Sips  of  very 
hot  water  or  swallowing  bits  of  ice  will  then  relieve  the  trouble  and  in  a 
little  while  the  free  use  of  water  may  be  continued. 

An  active  circulation  will  also  aid  in  the  elimination  of  the  ether;  and  this, 
together  with  the  stimulation  of  leucocytic  activity,  may  be  accomplished 
by  use  of  the  cold  mitten  friction  with  the  ice  bag  to  the  heart.  Both  these 
measures  increase  the  depth  of  respiration  and  the  volume  of  tidal  air  so 
that  more  thorough  ventilation  occurs. 

Considerable  importance  attaches  to  the  prevention  of  internal  congestions 
and  visceral  stasis  of  blood,  especially  in  the  lungs  and  about  the  site  of 
operation.  As  a  means  to  this  end  we  have  adopted  as  almost  a  matter  of 
routine,  the  use  of  the  hot  foot  bath,  the  hot  leg  pack  or  electro-thermal 
pack  to  the  legs  as  soon  as  convenient,  immediately  following  the  operation. 
If  the  hot  leg  pack  is  used,  a  dry  blanket  should  be  placed  next  to  the  skin. 
A  well  covered  ice  bag  is  placed  over  the  heart  at  the  same  time.  The 
treatment  is  continued  until  the  limbs  are  well  reddened  and  should  be  con- 
cluded by  a  cold  mitten  friction  to  the  same  skin  surface.  This  procedure 
will  usually  last  about  30  minutes.  It  will  probably  not  be  necessary  in  ordi- 
nary cases  to  repeat  it  for  several  hours  or  until  the  next  day. 

Transient  albuminuria  does  not  usually  require  any  special  treatment.  If 
albumin  and  casts  appear  in  the  urine,  derivative  treatment  is  indicated  and 
free  perspiration  should  be  encouraged.  Sweating  should  never  continue 
long  at  a  time. 

If  pneumonia  occurs,  use  derivative  measures  and  apply  the  cold  coil  or 
cold  compress  to  the  chest.  These  should  be  occasionally  interrupted  by 
the  application  of  a  fomentation  or  the  revulsive  compress  used.  The  ice 
bag  to  the  heart  and  the  cold  mitten  friction  are  also  of  great  service  in 
treating  post-operative  pneumonia.  For  further  details  see  article  on  pneu- 
monia in  Chapter  XIX. 

After  gall-bladder,  appendix,  tubal,  and  some  other  abdominal  operations, 
a  right  sided,  diaphragmatic  and  consequently  much  hidden  pleurisy  may 
appear.  It  is  usually  not  severe  and  will  respond  to  the  usual  treatment. 


PART    III 


TECHNIQUE 


FOMENTATIONS 

(Fo.) 

A  fomentation  is  a  local  application  of  moist  heat  by  means  of  cloths 
wrung  fron  hot  water. 

a.  Articles  Necessary.    In  well  equipped  treatment  rooms  the  fomenta- 
tion tank  should  be  so  arranged  that  the  water,  from  which  the  fomenta- 
tions are  to  be  wrung,  can  be  heated  by  a  coil  of  live  steam.     When  properly 
arranged  the  escape  of  steam  from  this  coil  into  the  water  will  be  noiseless 
and  cause  the  water  to  boil  more  vigorously  then  over  a  fire.     The  outlet  of 
the   tank  should  be  controlled  by  means  of  a  valve,  never  by  a  plug.     A 
wringer  with  extra  long  rollers  should  be  clamped  to  the  side  or  end  of  the 
tank  and  a  table  placed  immediately  beyond  the  wringer  on  which  the  fomen- 
tations may  be  wrapped.      If  treatment  is  given  at  the  patient's  residence  a 
boiler  or  pail  of  hot  water  may  be  used.     In  an  institution  it  is  rarely  neces- 
sary to  carry  a  pail  of  hot  water  to  the  patient's  room,  as  the  fomentations 
will  be  hotter  if  prepared  in  the  treatment  rooms  and  packed  in  a  pail  in  the 
manner  described  below.     The  nurse  should  also  be  provided  with  a  set  of  six 
fomentation    cloths,  two  Turkish  towels  for  drying  the  patient,  one  large 
cotton  sheet  for  covering  the  patient,  a  bowl  of  cold  water  or  ice  water  and 
one  or  two  hand  towels.     An  oil  cloth  and  extra  sheets  and  towels  will  be 
necessary  to  protect  the  bedding.     If  the  treatment  is  to  be  given  in  a  patient's 
room,  provide  a  grass  mat  on  which  the  pail  of  fomentations  or  hot  water 
may  be  placed.     If  the  pail  is  placed  on  a  carpet,  a  newspaper  may  be  all 
that  is  required.     When  the  pail  is  set  on  a  chair  with  a  newspaper  under 
it  the  heat  causes  the  paper  to  stick  to  the  varnish. 

b.  The  Patient.     All  clothing  should  be  removed.     If  the  clothing  is  not 
removed,  then  bare  a  longer  area  than  the  part  to  be  treated  and  thoroughly 
protect  the  clothing  by  thick  Turkish  towels.     See  that  the  feet  are  warm 
and  kept  so  during  treatment.     If  they  are  cold,  a  hot  foot  bath  should  be 
given,  or  hot  water  bottles  applied.     The  hot  foot  bath  is  much  more  effec- 
tive than  any  other  means  of  warming  the  feet. 

In  giving  fomentations  to  a  bed  patient  great  care  should  be  exercised  to 
avoid  steaming  the  bedding,  as  a  patient  may  easily  take  cold  because  of  bed 
linen  left  damp  after  treatment.  Protect  the  bedding  underneath  the 
patient  by  oil  cloth,  sheets  and  towels  as  necessary.  After  applying  a  fomen- 
tation, cover  it  with  another  dry  fomentation  or  a  newspaper  in  order  to  pro- 
tect the  bedding  over  the  patient. 

c.  The  Fomentation.     Prepare  a  set  of  four  or  six  fomentation  cloths, 
thirty  to  thirty-six  inches  square.     Four  of  these  may  be  cut  from  a  single 
blanket.     The  material  should  be  half  wool.     Three  cloths  are  necessary  for 
one  fomentation  where  they  are  to  be  very  hot — one  for  the  dry  covering 
and  two  to  be  wrung  from  boiling  water  for  the  inside  wet  part.     Where 


242  TECHNIQUE  OF  HYDROTHERAPY 

less  heat  is  required  one  iriside  cloth  may  be  sufficient.  Two  such  fomenta- 
tions are  necessary  if  the  best  results  are  to  be  obtained. 

Spread  out  on  the  table  the  cloth  for  the  dry  covering.  Fold  together  in 
three  thicknesses  so  as  to  make  a  long  narrow  piece,  the  cloth  or  cloths  to 
be  used  inside;  and  holding  the  strip  by  one  end,  immerse  in  the  boiling  water. 
When  thoroughly  saturated  with  the  boiling  water,  pass  it  quickly  through 
the  wringer  and  after  further  folding  or  re-adjusting  to  the  proper  shape  and 
size  for  the  part  to  be  treated,  fold  it  quickly  inside  the  dry  fomentation 
cloth.  It  is  now  ready  for  use.  By  again  doubling  together  the  surface  of 
the  fomentation  to  be  applied  to  the  patient,  it  can  be  carried  with  less  loss 
of  heat.  The  fomentation  should  be  large  enough  to  cover  a  much  larger 
area  than  the  part  affected. 

Where  it  is  necessary  to  wring  the  fomentation  by  hand,  partially  twist 
the  long  folded  piece  while  it  is  held  doubled  together  with  one  hand  holding 
each  end.  Both  ends  are  now  grasped  in  one  hand  and  the  fomentation 
dipped  into  the  boiling  water.  When  it  is  ready  to  wring,  twist  tightly, 
handling  the  fomentation  cloth  by  the  dry  ends.  Next,  pull  the  ends  apart. 
The  water  is  thus  squeezed  out.  The  twisting  and  pulling  may  be  repeated 
as  necessary  for  thorough  wringing  of  the  cloth.  By  releasing  one  end  while 
holding  up  the  cloth  by  the  other  it  may  be  quickly  untwisted  and  at  once 
wrapped  in  the  dry  covering. 

Where  it  is  necessary  to  give  the  treatment  in  the  patient's  room,  a  set 
of  three  fomentations  may  be  packed  in  a  papier  mache  pail  in  such  a  way 
as  to  preserve  their  heat  for  a  half  hour  or  even  longer.  First,  line  the 
pail  with  large,  dry  fomentation  cloths.  Prepare  each  fomentation'as  usual 
and  pack  in  tightly  or  better  still,  wring  by  hand  the  inside  cloths,  leaving 
them  twisted  as  tightly  as  possible  and  pack  closely  in  the  lined  bucket.  A 
hot  water  bottle  may  be  placed  in  the  bottom  of  the  pail  if  thought  neces- 
sary and  another  over  the  wet  cloths.  The  necessary  number  of  dry  fomen- 
tation cloths  may  be  packed  into  the  top  of  the  pail  and  the  fomentations 
made  up  in  the  room  as  needed. 

d.  Procedure.  The  fomentation  should  lie  closely  in  contact  with  the 
skin,  and  be  renewed  in  three  or  four  minutes;  or  in  case  of  pain,  as  soon  as 
it  becomes  comfortable.  If  unbearably  hot,  rub  the  part  with  the  hand  under 
the  fomentation  or  remove  the  moisture  by  firm  rubbing  once  or  twice  wich 
a  Turkish  towel  wrapped  about  the  hand.  The  fomentations  may  be  applied 
over  a  towel  in  order  to  temper  the  heat.  Always  be  careful  to  protect 
from  chilling,  the  area  being  treated  by  keeping  it  covered  with  the  fomen- 
tation cloth  or  a  towel. 

To  renew  the  fomentation,  prepare  another  similar  one  and  apply  immed- 
iately after  removing  the  moisture  occasioned  by  ihe  first.  Never  apply 
another  fomentation  until  this  is  done,  as  the  water  on  the  skin  makes  it 
more  difficult  t  >  endure  the  heat  of  the  newly  prepared  fomentation.  The 
second  fomentation  should  be  ready  to  apply  before  the  first  is  removed. 
The  removal  of  the  inside  cloth  from  the  outer  for  purposes  of  renewal  does 
not  give  the  best  results,  although  careful  attention  to  details  may  still 
make  the  treatment  very  effective. 

Unless  otherwise  indicated  or  ordered,    three  successive  applications  are 


LOCAL  APPLICATIONS  OF  HEAT  243 

made.  In  all  cases,  however,  they  should  be  continued  until  the  desired 
effect  is  obtained.  After  the  last  one,  the  part  should  be  immediately  cooled 
by  a  wet  hand  rub,  cold  compress,  or  rub  with  the  cold  wet  towel.  Dry 
thoroughly  and  cover  at  once  to  prevent  chilling.  In  some  cases  o*f  pain, 
the  part  should  be  dried  without  the  cold  applications.  All  changes  should 
be  made  quickly,  and  the  part  treated  should  never  be  left  uncovered. 

e.  Precautions.  Incasesof  unconciousness,  paralyzed  sensation,  diabetes, 
dropsy,  under  anesthesia  or  after  operations,  great  care  must  be  taken  to 
avoid  burning.  The  degree  of  each  application  should  be  tested  by  the  back 
of  the  hand  or  face  before  being  applied  to  the  patient.  In  fomentations  to 
the  face  or  other  sensitive  part,  gauze  should  be  placed  next  to  the  skin. 

In  case  of  general  perspiration,  a  general  cold  friction,  wet  hand  rub,  wet 
towel  rub  or  alcohol  rub  should  be  given. 

Sensitive  surfaces,  especially  bony  prominences  such  as  the  ilia,  costal 
arches,  clavicles  or  scapula  may  need  to  be  protected  by  extra  coverings  of 
flannel  or  Turkish  towel. 

Where  the  patient  is  liable  to  cerebral  congestion,  and  always  in  case  of 
fever,  apply  cold  compresses  to  the  head  and  also  to  the  neck  if  needed. 
The  same  should  be  done  where  two  or  more  applications  of  heat  are  made 
at  the  same  time  or  general  perspiration  induced.  In  case  of  heart  disease, 
usually  in  fever,  and  with  rapid  pulse  from  any  cause,  an  ice  bag  should  be 
placed  over  the  heart. 

In  order  to  relieve  pain,  the  fomentation  must  be  very  hot,  as  hot  as  can 
be  borne,  and  renewed  as  soon  as  it  becomes  comfortable.  In  some  cases 
of  pain  the  cold  application  at  the  close  should  be  omitted,  the  part  being 
dried  and  immediately  covered  with  flannel  or  other  dry  covering. 

For  sanitary  reasons  it  is  desirable  that  each  patient  furnish  his  own 
fomentation  cloths.  However,  persons  with  communicable  diseases  should 
not  be  admitted  to  a  general  treatment  room. 

f.  Effects.  The  fomentation  is  used  to  relieve  pain,  produce  derivation, 
as  a  preparation  for  cold  treatment  and  for  stimulating  or  sedative  effects, 
according  to  the  temperature  and  mode  of  application.  Its  first  effect  is 
that  of  a  vital  stimulant;  unless  followed  by  a  cold  application  the  reaction 
is  atonic.  A  brief  application  is  stimulating;  prolonged  applications  seda- 
tive or  depressing.  For  sedative  effects  the  heat  should  be  moderate  and 
the  application  more  prolonged  before  renewal. 

HOT  GAUZE  COMPRESS 
(H.  Comp.) 

This  is  used  when  it  is  desired  to  apply  moist  heat  to  such  sensitive  parts 
as  the  eye,  a  wound  or  infected  part  where  the  cloth  must  be  disinfected  or 
discarded  after  being  used. 

Several  thicknesses  of  gauze,  cheesecloth  or  ordinary  cotton  cloth  of 
appropriate  size  and  shape,  are  wrung  from  boiling  water  and  applied  in  the 
same  way  as  a  fomentation.  Because  the  compress  is  usually  small  and 
unprotected,  it  cools  quickly,  and  for  this  reason  must  be  more  frequently 
renewed,  nor  does  cotton  hold  heat  as  long  as  wool.  From  ten  to  fifteen 


244  TECHNIQUE  OF  HYDROTHERAPY 

minutes    will    usually  suffice  to  obtain  the  desired  result.      The  treatment 
should  be  concluded  in  a  manner  similar  to  the  fomentation. 

STUPES 

A  stupe  consists  in  the  application  of  a  medicament  by  means  of  a  fomen- 
tation. When  gauze  compresses  are  used,  the  disinfectant  or  medicament 
may  be  put  into  the  hot  water  from  which  the  compress  is  wrung.  In  case 
of  a  large  fomentation  with  flannel  cloths,  the  medicament  may  be  applied 
by  compresses  placed  under  the  fomentation.  Turpentine,  mustard,  menthol, 
etc.,  may  be  used  in  this  way.  However,  the  desired  hyperemia  and  deple- 
tion can  usually  be  obtained  in  a  more  cleanly  manner  by  a  plain  fomenta- 
tion, and  without  the  danger  of  a  blister. 

In  preparing  the  gauze  or  muslin  for  a  mustard  fomentation,  use  one 
teaspoonful  of  mustard  to  a  cup  of  hot  water.  Spread  out  this  mustard 
compress  on  the  surface  to  be  treated  and  cover  with  an  ordinary  fomenta- 
tion. 

REVULSIVE  COMPRESS 
(Rev.  Comp.) 

This  is  given  in  the  same  manner  as  the  fomentation,  with  the  addition 
of  a  cold  compress  after  each  application  of  heat.  A  hand  towel  is  wrung 
from  cold  water  or  ice  water,  according  to  the  ability  of  the  patient  to  react. 
This  is  spread  out  over  the  surface  immediately  on  the  removal  of  the  fomen- 
tation, allowed  to  remain  a  few  seconds,  and  then  turned  over  and  allowed 
to  remain  about  thirty  seconds.  The  skin  is  now  dried  and  the  next  fomen- 
tation applied.  Three  changes  of  hot  and  three  of  cold  are  usually  employed. 

The  revulsive  compress  is  a  mild  stimulant  and  tonic  measure,  it  also  pro- 
duces mild  fluxion  in  the  part  treated. 

ALTERNATE  HOT  AND  COLD  TO  SPINE 
(H.  &  C.  Sp.) 

Fomentations  are  given  in  the  same  manner  as  for  the  revulsive  compress. 
After  each  a  smooth  piece  of  ice  is  quickly  rubbed  back  and  forth  over  the 
part,  making  from  three  to  five  or  more  to-and-fro  movements.  The  part 
is  then  dried  and  another  fomentation  applied.  In  making  these  hot  and 
cold  applications,  the  next  fomentation  should  be  ready  before  the  ice  is 
applied. 

Alternate  hot  and  cold  applications  may  be  made  to  other  parts  in  the 
same  manner. 

Alternate  hot  and  cold  to  the  spine  is  a  vigorous  stimulant  and  tonic  meas- 
ure and  is  useful  in  a  great  variety  of  conditions. 

ALTERNATE  HOT  AND  COLD  TO  HEAD 
(H.  &  C.  Hd.) 

a.  Articles  Necessary:  Two  compresses  of  three  to  five  thicknesses  of 
gauze  or  cheesecloth  about  twelve  inches  square. 

Two  ice  bags  filled  with  finely  chopped  ice  and  covered  with  cheesecloth. 


LOCAL  APPLICATIONS  OF  HEAT  245 

A  spine  bag  partly  filled  with  hot  water  and  covered  with  a  fomentation 
cloth  or  towel. 
A  bowl  of  ice  water  and  a  pail  of  boiling  water. 

b.  Procedure.     Place  the  spine  bag  crosswise  of  the  cervical  spine,  bring- 
ing it  well  up  under  back  of  head  and  neck. 

Lightly  wring  cheesecloth  from  ice  water  and  apply  to  face,  covering  top 
of  head  and  ears.  Press  down  firmly  over  forehead  and  temporal  arteries; 
renew  every  minute. 

After  three  minutes  replace  spine  bag  by  two  cloth-covered  ice  bags,  and 
the  cold  compress  to  face  by  another  wrung  quite  dry  from  hot  water;  the 
latter  should  be  renewed  every  minute.  In  another  three  minutes  replace 
the  first  applications  of  spine  bag  to  the  back  of  the  neck  and  cold  compress 
to  the  face.  Continue  these  alternations  for  three  complete  sets  of  hot  and 
cold.  Cool  all  the  parts  by  wiping  off  with  a  cold  compress  and  dry  thor- 
oughly, especially  the  hair. 

c.  Effect.     These  alternating  hot  and  cold  applications  stimulate  the  cere- 
bral circulation  and  the  treatment  is,  therefore,  indicated  in  headache  due 
to  anemia  of  the  brain,  also  in  passive  congestion  and  in  a  cold  in  the  head. 
Any  alternating  hot  and  cold  application  produces  fluxion. 

SIMULTANEOUS  HOT  AND  COLD  TO  HEAD 
(Simul.  H.  &  C.  Hd.) 

Place  an  ice  bag  to  the  base  of  the  brain  and  another  ice  bag,  or  better, 
ice  cap  to  the  vertex  after  moistening  the  hair  so  that  the  cold  will  pene- 
trate. Also  place  ice  bags  or  ice  compresses  over  the  carotids.  Now  apply 
a  fomentation  to  the  face,  covering  the  ears  and  forehead.  Gauze  or  cheese- 
cloth should  be  used  under  the  fomentation  when  applied  to  the  face.  The 
nose  should  not  be  covered  by  the  fomentation  as  it  is  uncomfortable  when 
so  done,  and  it  is  better  for  the  patient  to  breathe  cooler  air. 

This  treatment  is  very  effective  in  reducing  cerebral  congestion  and  reliev- 
ing congestive  headache.  It  is  well  to  conclude  the  treatment  by  an  alter- 
nate hot  and  cold  percussion  douche  to  the  feet,  cold  cervical  and  cephalic 
compresses  being  kept  on  during  the  douche. 

Simultaneous  applications  of  heat  and  cold  so  given  that  the  cold  applica- 
tion is  placed  over  a  reflex  area  of,  or  the  large  artery  supplying,  the  deep 
part,  produce  depletion. 

HOT  WATER  BOTTLES 

These  should  be  partly  filled  with  hot  water  (never  boiling  water)  and 
wrapped  in  cloth,  preferably  flannel  or  a  Turkish  towel.  Great  care  should 
be  taken  in  applying  them  to  patients  with  paralysis  and  during  and  after 
operations  that  burns  do  not  result.  The  safety  of  the  hot  water  bottle  may 
be  tested  by  holding  it  against  the  cheek.  When  not  in  use,  the  bottle  should 
be  hung  bottom  end  up  with  the  stopper  out.  It  should  never  be  left  doubled 
sharply  upon  itself  as  it  is  likely  to  crack  at  the  fold. 

Fomentations  may  be  re-enforced  or  prolonged  by  the  use  of  hot  water 


246  TECHNIQUE  OF  HYDROTHERAPY 

bottles,  or  the  bag  may  be  wrapped  in  a  moist  cloth  covered  over  by  a  dry 
one,  to  give  the  effects  of  a  mild  fomentation. 

WINTERNITZ  COIL 

This  consists  of  a  matted  coil  of  rubber  tubing  about  ten  or  eleven  inches 
in  diameter,  through  which  a  stream  of  hot  water  is  caused  to  flow.  A  dry 
blanket  is  placed  on  the  treatment  table,  and  over  this  is  placed  a  doubled 
sheet,  wrung  from  cold  water  or  ice  water,  so  that  it  may  be  wrapped  about 
the  trunk.  The  patient  lies  down  on  the  wet  sheet  and  one  end  is  wrapped 
tightly  about  the  chest  and  abdomen.  The  coil  is  now  placed  on  the  abdo- 
men over  the  wet  sheet,  and  the  other  end  of  the  sheet,  wrapped  around 
the  trunk  over  the  coil.  The  dry  blanket  is  folded  over  and  about  the  patient. 
A  small  stream  of  hot  water  at  135°  flows  slowly  through  the  coil  from  the 
center  outwards.  The  treatment  is  continued  from  thirty  to  forty  minutes, 
or  even  three  hours  in  cases  of  very  slow  and  defective  digestion.  It  is  con- 
cluded by  a  cold  mitten  friction.  A  hot  water  bottle  may  be  used  in  place 
of  the  coil.  (See  hot  and  heating  trunk  pack.) 

The  coil  may  be  used  for  cold  water  in  the  same  manner  as  the  Leiter 
coil.  In  fact  the  cold  coil  is  much  more  frequently  used  and  for  a  greater 
number  of  purposes  than  the  hot  coil. 

RADIANT  HEAT 
(Rad.  Heat) 

The  radiant  heat  is  a  local  application  of  heat  by  means  of  electric  lights 
arranged  in  a  reflecting  metal  case.  From  one  to  twelve  or  more  such  lights 
may  be  arranged  in  a  single  case,  and  the  case  so  constructed  as  to  fit  to 
any  part  of  the  body.  An  instrument  with  one  light  is  perhaps  the  most 
useful.  An  oblong  case  containing  three  lights  is  a  convenient  means  of 
applying  heat  to  the  spine.  A  case  in  the  shape  of  a  half  cylinder  and  con- 
taining six  or  more  lights  may  be  made  for  the  feet  and  legs. 

In  applying  the  radiant  heat,  the  body  should  be  protected  from  the  edge 
of  the  case  by  towels  or  fomentation  cloths.  The  amount  of  heat  may  be 
regulated  by  the  number  of  lights  or  the  distance  from  the  skin.  Leave  in 
place  for  ten  to  twenty  minutes,  or  until  the  desired  results  are  obtained. 
Cover  the  part  well  after  drying  perspiration,  or  use  a  cold  wet  towel. 


LOCAL  APPLICATIONS  OF  COLD 

COLD  COMPRESS 

(C.  Comp.) 

A  cold  compress  is  a  local  application  of  cold  by  means  of  a  cloth  wrung 
from  cold  water.  Hand  towels  or  ordinary  cotton  cloths  may  be  used. 
These  should  be  folded  to  the  desired  size,  and  wrung  from  cold  water  or 
ice  water.  The  wringing  should  be  just  sufficient  to  prevent  dripping. 
They  will  be  colder  if  taken  immediately  from  a  block  of  ice.  As  a  continu- 
ous cold  application,  the  compress  must  be  very  frequently  renewed,  always 


LOCAL  APPLICATIONS  OF  COLD  247 

before  it  is  warmed  to  any  great  extent.  The  thicker  the  compress,  the  less 
frequently  will  it  require  renewal.  A  set  of  two  compresses  should  be  used 
and  renewed  at  intervals  of  from  one  to  five  minutes  depending  on  the 
thickness  of  the  compress  and  the  result  to  be  obtained.  Cold  compresses 
may  be  applied  to  the  head,  neck,  over  the  heart  or  lungs,  to  the  abdomen, 
spine,  etc.  When  applied  to  the  head  they  should  be  pressed  firmly  down 
on  the  surface  being  treated,  especially  over  the  forehead  and  the  temporal 
arteries.  The  pillow  should  be  protected  by  rubber  cloth  covered  by  a  towel. 
When  applied  to  the  abdomen  in  typhoid  fever  the  bedding  and  patient's 
garments  should  be  protected  by  Turkish  towels. 

When  applied  over  a  large  artery  it  decreases  the  amount  of  blood  in  the 
part  beyond  the  application.  Such  an  application  is  called  a  proximal  com- 
press. Examples  of  this  are  found  in  such  applications  as  a  cold  compress 
to  the  neck,  over  the  femoral  artery,  at  the  bend  of  the  elbow,  etc.  Ice 
bags  are  also  used  for  the  some  purpose. 

ICE  PACK 

(Ice  Pk.) 

An  ice  pack  is  used  where  a  large,  continuous  and  very  cold  application  is 
desired.  Spread  cracked  ice  over  a  thick  Turkish  towel,  folding  one  end 
and  the  edges  over  this  so  as  to  retain  the  ice.  Apply  next  to  the  skin  or  over 
a  single  layer  of  flannel.  This  may  be  used  over  the  heart,  also  over  a  con- 
solidated lung  area  in  pneumonia.  In  the  latter  case,  it  should  never  be 
applied  until  after  the  hot  packs  used  in  this  disease  have  warmed  the  body 
sufficiently  to  prevent  chilling.  It  should  occasionally  be  interrupted  by 
applying  a  fomentation.  This  helps  to  preserve  the  desired  reflex  effect. 

Snow  may  be  used  in  place  of  the  pounded  ice.  In  applying  an  ice  pack  to 
a  joint  first  wrap  the  part  in  flannel  so  as  to  prevent  actual  freezing,  then 
pack  the  snow  or  pounded  ice  closely  against  the  flannel  forming  a  layer 
about  one  inch  thick,  retaining  it  in  place  by  a  larger  flannel  cloth  wrapped 
about  all  and  pinned  together. 

Ice  packs  should  be  interrupted  often  enough  to  prevent  freezing  and  the 
part  either  rubbed  with  snow  or  a  fomentation  applied  to  renew  the  local 
reaction. 

ICE  CRAVAT 

The  ice  cravat  or  collar  is  made  in  the  same  way  as  the  ice  pack,  the  towel 
being  filled  with  ice  and  folded  so  as  to  be  about  three  inches  wide  and  encir- 
cle the  neck.  If  the  towel  is  wrung  from  ice  water,  it  must  be  more  fre- 
quently renewed  than  when  cracked  ice  is  used. 

An  ice  cravat  may  also  be  made  by  using  two  narrow  spinal  ice  bags. 
These  should  be  filled  with  pounded  ice  and  wrapped  in  a  linen  or  cotton 
cloth. 

The  effect  is  that  of  a  proximal  application.  The  carotid  arteries  and 
and  their  distal  branches  are  contracted^  also  the  vertebral  arteries.  Thus 
the  blood  supply  to  the  brain  and  head  generally  is  very  much  lessened. 
The  ice  collar  is  frequently  used  in  fever,  in  congestive  headache,  in  acute 


248  TECHNIQUE  OF  HYDROTHERAPY 

epidemic  meningitis,  etc.     It  should  also  be  used  in  sunstroke  and  whenever 
prolonged  sweating  treatments  are  given  as  in  eclampsia  and  uremia. 

ICE  BAG  AND  ICE  CAP 

(Ice  Bg.) 

Ice  bags  are  made  in  various  shapes  and  sizes.  The  best  ice  bags  are 
made  of  pure  gum  rubber  and  are  usually  elliptical  in  shape.  They  may  be 
obtained  in  almost  any  size  desired.  The  spinal  ice  bag  is  about  three  inches 
wide  by  seven  to  nine  or  ten  long. 

Ice  caps  are  usually  round  or  elliptical  and  provided  with  a  screw  cap; 
some  are  also  made  with  loops  for  holding  them  in  place.  Cloth  covered 
ice  bags  offer  no  advantage,  they  usually  leak  after  being  used  a  few  times 
and  are  also  unsanitary.  The  ice  bag  or  cap  should  be  filled  with  finely 
cracked  or  pounded  ice,  never  with  large  chunks.  In  the  case  of  the  ice  bag, 
the  neck  should  be  doubled  down,  then  folded  several  times  across  this,  and 
tied  with  tape  about  one-fourth  inch  wide.  Thread  or  fine  twine  should  not 
be  used,  as  it  cuts  the  rubber.  When  applying  the  bag,  wrap  it  in  a  towel 
or  one  thickness  of  flannel.  The  skin  should  not  be  severely  chilled.  The 
bag  should  be  removed  often  enough  to  prevent  this,  the  part  rubbed  briskly 
with  the  hand  until  warmed  or  a  fomentation  applied  for  a  short  time. 

COLD  WATER  COIL 

(C.  Coil) 

The  rubber  coil  (Winternitz  coil)  is  the  most  convenient  means  of  apply- 
ing a  local  application  of  cold.  Matted  coils  ten  or  eleven  inches  in  diameter 
may  be  purchased  or  a  coil  may  be  made  of  ordinary  rubber  tubing  and  held 
together  by  adhesive  tapes.  The  inflow  should  enter  at  the  center  of  the 
coil.  The  rate  of  flow  may  be  very  conveniently  controlled  by  tying  a  knot 
in  the  outflow  tube  just  above  where  it  dips  into  the  receiving  pail.  This 
knot  may  be  loose  or  tight  as  desired  for  rapid  or  slow  flowing  of  the  cold 
water  through  the  coil.  The  reservoir  should  be  about  two  feet  above  the 
level  of  the  coil  and  may  be  a  large  can  with  an  outlet  at  the  bottom,  or  an 
ordinary  pail  may  be  used  and  the  outflow  secured  by  siphonage. 

The  coil  should  always  be  applied  over  a  cold  compress  and  covered  with 
a  dry  flannel  cloth  or  dry  fomentation  cloth.  In  applying  it  to  the  head  the 
coil  may  be  moulded  into  the  shape  of  a  cap  and  held  in  place  by  light  band- 
ages or  folded  towels.  Always  wet  the  hair  before  placing  the  coil. 

The  Leiter  coil  is  not  used  as  much  as  the  rubber  coil.  It  is  a  small  flat 
coil  of  flexible  metal  tubing  through  which  a  stream  of  cold  water  or  ice 
water  passes.  It  may  be  moulded  to  fit  any  part,  and  is  often  used  over  the 
mastoid.  The  principle  is  the  same  as  that  of  the  Winternitz  coil. 


HEATING  COMPRESSES 

A  heating  compress  is  a  cold  compress  so  covered  that  warming  up  soon 

occurs.       The  effect  is,  therefore,  that  of  a  mild  application  of  moist  heat. 

A  heating  pack  or  compress  consists  of  an  application  of  heat  to  the  body 


HEATING  COMPRESSES  249 

by  means  of  three  or  four  thicknesses  of  gauze  or  one  of  linen  or  cotton 
cloth  wrung  from  cold  water  and  so  perfectly  covered  with  dry  flannel  or 
mackintosh  and  flannel  as  to  prevent  the  circulation  of  air  and  cause  an 
accumulation  of  body  heat.  In  case  warming  does  not  occur  promptly,  it 
should  be  aided  by  hot  water  bottles  or  the  radiant  heat.  It  is  usually  left 
in  place  for  several  hours  between  other  treatments,  or  over  night.  If  left 
on  over  night  it  should  be  dry  by  morning  unless  an  impervious  covering 
such  as  a  mackintosh  or  oiled  silk  is  used.  On  removal  of  the  compress  the 
part  should  be  rubbed  with  cold  water. 

According  to  the  extent  and  location  of  the  surface  involved,  the  nature 
and  thickness  of  the  coverings,  the  temperature  and  the  amount  of  water 
left  in  the  wet  cloth,  and  the  duration  of  the  application,  it  may  have  the 
following  effects,  viz., — tonic,  sedative,  derivative  or  sweating. 

If  the  pack  dries  out  before  being  removed,  it  will  have  a  mild  derivative 
and  a  mild  sedative  or  tonic  effect  according  to  the  part  to  which  it  is  applied 
and  the  condition  in  which  it  is  used.  If  the  coverings  prevent  drying,  the 
result  will  be  that  of  a  stronger  derivative  because  of  the  local  sweating. 
It  also  causes  relaxation  of  the  muscles  and  vasodilatation  of  the  vessels  in 
immediate  or  reflex  relation  with  the  surface  treated. 

MOIST  CHEST  PACK 
(Ch.  Pk.) 

Any  sort  of  a  jacket  which  combines  the  above  requisites  for  a  heating 
compress  with  ease  and  neatness  of  application  and  accuracy  of  fit,  will 
answer  the  purpose  of  a  chest  pack. 

The  roller,  square  and  fitted  chest  packs  are  examples  of  these. 

1.  Roller   Chest   Pack.    The   inside  piece  consists  of  two  to  five  thick- 
nesses of  gauze  eight  to  ten  inches   wide    and  about   six  or   eight  feet  in 
length.     One  thickness  of  thin  linen  may  be   used.     The   outside  piece   of 
flannel  is  a  little  wider  than  the  gauze  and  somewhat  longer.     The  gauze 
or  linen  is  loosely  rolled  in  bandage  form    and  wrung  nearly  dry  from  cold 
water.     While  standing  in  front  of  the  patient  the  end  is  applied  under  one 
arm,  more  handily  the  right,  then  carried  diagonally  across  the  front  of  the 
chest  and  over  the  left  shoulder,  then  obliquely  across  the  back,  under  the 
right  arm  and  directly  across  the  front  of  the  chest,  under  the  left    arm, 
across  the  back  and  over  the  right  shoulder  and  fastened  under  the  trans- 
verse front  piece.     The  bandage  must  be  snugly  applied  at  all  places  but 
not  so  tight  as  to  restrict  the  movements  of  the  chest.     The  flannel  is  now 
applied  in  the  same  order,  care  being  taken  that  the  wet  piece  is  well  covered 
and  then  securely  fastened  with  safety  pins.     The  pack  should  be  comfort- 
able and  feel  warm  in  a  very  short  time. 

2.  Square  Chest  Pack.      Both  parts  of  the  pack  are  of  an  oblong  form, 
wide  enough  to  reach  from  the  top  of  the  shoulder  to  the  lower  ribs,  and  long 
enough  to  give  a  double  thickness  in  front.     The  ends  of  the  bandage  are 
slit  into  two  strips  one-third  and  two-thirds  respectively  of  the  total  width, 
and  each  one-third  of  the  length.     The  outer  flannel  part  should  be  about  two 
inches  wider    and    of  the  same  length  and  slit  in   the  same  fashion.      The 
flannel  part  should  be  spread  out  on  the  treatment  table  and  the  linen  over 


250  TECHNIQUE  OF  HYDROTHERAPY 

it  after  being  wrung  from  cold  water.  The  patient  now  lies  back  on  this. 
The  narrow  strips  are  brought  up  over  the  shoulder  and  across  the  chest. 
The  top  of  the  wider  strips  should  fit  under  the  axilla  and  be  brought  across 
the  chest.  The  flannel  should  now  be  applied  in  the  same  manner  and  at 
all  loose  places  be  drawn  tight  or  folded  in  and  the  whole  fastened  with 
safety  pins. 

3.  Fitted    Chest  Pack.     From  flannel    cut  a    front   and    a  back  piece  in 
much  the  same  shape  as  for  a  vest  making  the  necessary  carved  cuts  about 
the  arms  and  neck.     The    front  piece  should  be  the  larger  so  as  to    come 
back  under  the  arms  and  lap  over  the  back  piece;  also  on  each  side  of  the 
neck,  a  strip  four  inches  wide  should  be  made  long  enough  to  overlap  the 
back  piece. 

An  inside  piece  of  the  same  shape  should  be  cut  from  gauze  or  thin  linen. 
This  inside  piece  should  be  about  one  and  one  half 'inches  narrower  at  all 
edges  so  that  when  covered  by  the  flannel  it  will  not  be  exposed  at  any 
place  but  be  covered  at  least  one  inch  beyond  its  edge. 

After  applying  see  that  it  fits  snugly  and  is  well  pinned  with  safety  pins 
so  as  to  prevent  the  entrance  of  air  at  any  place  along  the  edges. 

Various  other  forms  may  be  improvised  to  meet  the  needs  of  the  home 
not  provided  with  the  more  perfect  requisites.  To  retain  the  moisture  and 
so  give  greater  sweating  effects  the  cloth  may  be  covered  with  machintosh, 
gossamer  cloth  or  oiled  silk  of  the  same  size  and  shape. 

4.  Partial  Chest  Pack.     It  is  often  desirable  to  apply  the  moist  cloth  to 
only  a  portion  of  the  chest.     The  gauze  or  linen  may  be  cut  to  any  desired 
shape  and  size  and  applied  to  the  proper  area  under  the  square  or  roller  flan- 
nel  pack.     The  chest  being  covered  principally  by  dry  flannel,    this   form 
approaches  in  effect  the  dry  pack. 

DRY  CHEST  PACK 
(Dry  Ch.  Pk.) 

With  the  dry  chest  pack  only  the  flannel  is  used  of  either  the  roller,  square 
or  fitted  style.  It  should  usually  be  applied  over  a  thin  undergarment.  The 
dry  chest  pack  is  desirable  in  thin  persons,  the  aged  and  those  having  insuffi- 
cient body  heat  to  warm  up  the  wet  pack.  It  is  often  difficult,  not  to  say 
impossible,  in  the  case  of  a  thin  person,  to  pin  the  wet  pack  so  tightly  as  to 
prevent  the  air  from  circulating  under  the  edges  of  the  pack  and  yet  loose 
enough  to  be  comfortable  and  not  restrict  the  breathing.  '  In  many  cases 
a  chamois  vest  may  be  worn  over  a  thin  undergarment  to  produce  the  effects 
of  a  dry  pack. 

Chest  packs  are  of  much  benefit  in  pleurisy,  colds,  influenza  of  the  respir- 
atory type,  during  convalescence  from  pneumonia,  in  asthma,  whooping 
cough,  croup,  etc.  Under  the  pack,  the  skin  should  be  warm  and  gently 
perspiring.  The  choice  of  a  dry  or  moist  pack  will  depend  upon  the  vitality 
of  the  patient  and  the  result  to  be  obtained. 

MOIST  ABDOMINAL  BANDAGE 
(M.  A.  B.) 

The  Umschlag  or  moist  abdominal  girdle  is  one  of  the  most  useful  of  the 
heating  compresses.  The  inside  part  of  the  girdle  consists  of  one  thickness 


HEATING  COMPRESSES  251 

of  linen  or  three  or  four  of  gauze,  eight  or  nine  inches  wide  and  a  little  more 
than  one  and  one-half  times  the  circumference  of  the  body.  The  outer  flan- 
nel girdle  should  be  about  twelve  inches  wide  and  of  the  same  length.  The 
dry  flannel  is  placed  across  the  table  and  the  gauze,  wrung  nearly  dry  from 
cold  water,  placed  over  it.  The  patient  now  lies  back  on  the  bandage  so 
that  the  lower  edge  will  be  below  the  iliac  crests.  Each  end  of  the  wet 
linen  or  gauze  is  pulled  tightly  across  the  abdomen  and  tucked  under  the 
opposite  side.  Both  ends  of  the  flannel  are  now  folded  tightly  over  these 
and  securely  fastened  with  safety  pins.  Darts  may  be  taken  on  each  side 
by  means  of  safety  pins  in  the  same  manner  as  in  pinning  a  bandage  after 
an  abdominal  operation.  The  flannel  piece  should  project  one  and  one-half 
or  two  inches  beyond  the  wet  gauze  or  linen.  Where  it  is  difficult  for  the 
patient  to  warm  up  the  bandage,  it  may  be  moistened  only  over  the  abdo- 
men. 

The  moisture  may  be  retained  by  a  bandage  of  oiled  silk  or  mackintosh  of 
the  same  width  as  the  linen  and  applied  between  it  and  the  flannel.  This  is 
spoken  of  as  a  protected  girdle. 

The  sweating  underneath  will  be  more  profuse  than  without  the  imper- 
vious covering.  Since  the  moisture  is  retained  it  will  not  be  dry  by  morn- 
ing. The  protected  girdle  is  indicated  in  hyperacidity  and  where  it  is  desir- 
able to  produce  considerable  relaxation. 

The  ordinary  moist  abdominal  bandage  is  useful  in  nearly  all  forms  of 
atonic  indigestion,  in  neurasthenia,  anemia  of  the  liver,  insomnia,  catarrhal 
jaundice,  constipation,  etc.  In  these  conditions  it  is  usually  worn  only  at 
night. 

HEATING  THROAT  COMPRESS 

Four  to  six  thicknesses  of  cheesecloth  or  two  or  three  of  ordinary  cotton 
cloth  about  three  inches  wide  and  long  enough  to  encircle  the  neck  twice 
are  used  inside.  The  outside  consists  of  two  thicknesses  of  flannel  not  less 
than  four  inches  wide.  This  compress  being  small,  considerable  water  may 
be  left  in  it  and  still  be  found  dry  by  morning.  The  neck  should  be  rubbed 
with  cold  water  immediately  after  removing  the  compress  in  the  morning. 
The  "cold  cloth  around  the  neck"  is  a  very  common  household  remedy  for 
sore  throat,  hoarseness,  tonsilitis,  etc.  It  is  indeed  a  very  efficient  meas- 
ure; its  usefulness  can  hardly  be  overestimated.  The  heating  throat  com- 
press is  indicated  in  pharyngitis,  acute  laryngitis,  tonsilitis,  quinsy  and  in 
inflammation  of  the  Eustachian  tube.  It  is  also  useful  in  clergyman's  sore 
throat.  In  tonsiiitis,  quinsy  and  inflammation  of  the  Eustachian  tube,  the 
compress  should  extend  upward  about  the  lower  part  of  the  ear  and  may  be 
held  in  place  by  a  bandage  over  the  top  of  the  head. 

HEATING  JOINT  COMPRESS 

Heating  compresses  may  be  applied  to  the  foot,  ankle,  knee,  hand,  wrist, 
etc.  Rarely  more  than  two  thicknesses  of  gauze  are  used.  It  is  often 
necessary  to  use  cotton  for  a  covering  to  obtain  close  application  to  the  skin 
surface.  This  may  be  held  in  place  by  a  three-inch  roller  bandage  or  a 
broad  flannel  cloth.  A  dry  pack  may  be  made  of  cotton  or  soft  flannel  alone. 
In  certain  cases  the  joints  may  be  rubbed  with  a  medicated  solution  before 


252  TECHNIQUE  OF  HYDROTHERAPY 

being  covered,  or  the  gauze  dipped  in  it.  Alkaline  or  anodyne  solutions  are 
very  frequently  used  in  this  way  in  cases  of  rheumatism.  In  rheumatic 
fever  the  joints  may  be  rubbed  with  synthetic  oil  of  wintergreen  before  the 
heating  compress  is  applied.  It  helps  to  relieve  the  pain  and  by  its  action 
as  a  counter-irritant,  the  heating  and  circulatory  effects  are  enhanced. 

MEDICATED  COMPRESSES 

Besides  rubbing  the  parts  with  medicaments  such  as  turpentine,  camphor- 
ated oil,  oil  of  wintergreen,  etc.,  before  applying  the  heating  compress  or 
pack,  the  gauze  may  be  wrung  from  various  solutions  such  as  an  alcoholic 
solution  of  menthol,  mustard  water,  watery  solution  of  bicarbonate  of  soda, 
saltpeter,  etc.  When  counter-irritant  drugs  are  used  the  effect  of  the 
heating  compress  is  intensified.  It  is  usually  not  desirable  to  produce  a 
blister.  For  this  reason  the  use  of  coal  oil  and  turpentine  should  be  discour- 
aged. Not  only  may  they  produce  blisters,  but  being  inflammable,  they  are 
also  dangerous. 


POULTICES 

Poultices  are  very  popular  substitutes  for  the  heating  compress  and  have 
a  similar  effect.  They  consist  of  a  mixture  of  various  substances,  having 
the  consistency  of  mush  and  must  be  applied  hot  to  produce  the  desired 
result.  Flaxseed,  onions,  etc.,  are  commonly  used.  The  preparation  may 
be  applied  directly  to  the  skin  or  spread  on  a  cloth  and  bound  tightly  to  the 
part.  They  are  often  disagreeable  not  to  say  uncleanly. 

Probably  the  most  useful  poultice  is  that  consisting  of  white  clay  and 
glycerine  sold  under  various  names.  It  is  applied  hot  about  one-quarter  to 
one-half  an  inch  thick  and  covered  with  cotton  and  a  bandage.  The  results 
are  partly  due  to  the  heat  and  partly  to  the  water-absorbing  (hygroscopic) 
properties  of  the  glycerine. 

The  charcoal  poultice  is  especially  valuable  in  foul,  sloughing  ulcers  or 
wounds.  It  may  be  prepared  of  charcoal  alone  or  by  adding  equal  parts  of 
flaxseed  meal  and  powdered  charcoal  to  boiling  water  until  the  resulting 
mixture  is  the  consistency  of  mush.  This  is  evenly  spread  on  a  cloth  and 
applied  to  the  part,  or  directly  on  the  part  and  covered  with  a  muslin  cloth 
and  some  impervious  cloth  as  oiled  silk. 


TONIC  FRICTIONS 

A  tonic  friction  is  an  application  of  cold  water  so  combined  with  friction 
as  to  produce  decided  thermic  and  circulatory  reaction.  The  effects  are 
briefly  described  as  stimulant  and  tonic.  These  have  been  discussed  in 
detail  in  the  chapter  on  Stimulants  and  Tonics,  q.  v. 

Given  in  the  order  of  their  severity  the  tonic  frictions  are  as  follows: 
Wet  hand  rub,  cold  mitten  friction,  cold  towel  rub,  wet  sheet  rub,  and  drip- 
ping sheet  rub.  To  these  may  be  added  the  ice  rub  and  salt  glow.  While 


TONIC  FRICTIONS  253 

the  latter  is  not  particularly  an  application  of  cold,  the  friction  gives  tonic 
results  similar  to  the  others  and  the  procedure  is  not  far  different.  The  ice 
rub  may  be  used  for  stimulant  or  tonic  purposes  but  it  is  more  frequently 
used  as  an  antipyretic. 

COLD  MITTEN  FRICTION 
(C.  M.  F.  or  Cmf.) 

a.  Articles  Required.  A  bowl  or  pail  of  cold  water  at  50°  or  60°  F.  or 
ice  water,  a  sheet,  three  Turkish  towels,  two  friction  mitts  made  of  such 
coarse  material  as  woolen  moreene,  and  compresses  for  the  head  and  neck. 

6.  Procedure.  The  patient  should  be  warmly  covered  and  the  feet 
warm,  if  not,  give  hot  foot  bath.  Bare  one  part  of  the  body  at  a  time.  Do 
not  expose  any  part  longer  than  necessary;  dry  quickly  and  thoroughly  and 
recover  at  once  with  warm  dry  covering.  Before  beginning  the  regular  part 
of  the  treatment  bathe  the  patient's  face  and  neck  with  cold  water  or  apply 
cold  compresses  to  the  head  and  neck.  This  is  especially  necessary  in  treat- 
ing patients  with  valvular  heart  disease.  In  this  condition  an  ice  bag 
should  be  placed  over  the  heart  before  beginning  the  treatment.  In  other 
conditions  it  is  not  usually  necessary. 

Beginning  with  the  right  arm,  place  one  towel  under  the  arm  and  another 
around  the  shoulder  to  protect  the  table  and  patient.  With  the  mitts  on  the 
hands,  dip  them  into  cold  water  and  shake  or  squeeze  out  the  excess  of 
water.  While  the  patient  holds  the  arm  vertically,  rub  the  arm  and  hand 
with  rapid  to-and-fro  friction  movements  until  it  is  in  a  glow.  Quickly 
remove  mitts,  dropping  them  into  the  bowl  and  cover  the  entire  arm  with 
one  of  the  Turkish  towels,  having  the  patient  hold  the  upper  corners  by 
closing  the  hand  on  them.  Dry  by  friction  outside  the  towel,  and  then  rub 
with  the  towel  until  the  arm  is  thoroughly  dry  and  well  reddened.  Treat 
the  left  arm  in  the  same  manner. 

Now  covering  the  rest  of  the  body,  bare  the  chest  and  abdomen.  Tuck  a 
Turkish  towel  snugly  under  each  side  along  the  trunk  and  over  the  arms. 
Rub  the  chest  with  the  mitten  dipped  in  cold  water  in  a  manner  similar  to 
the  arms,  then  cover  the  entire  chest  with  one  of  the  towels  and  have  the 
patient  catch  the  two  upper  corners  as  they  lie  next  to  the  shoulders.  Rub 
briskly  with  downward  strokes  over  the  towel.  Then  wrapping  the  towel 
neatly  about  the  right  hand,  again  rub  the  entire  surface,  around  shoulders 
and  down  the  sides  so  as  to  dry  all  parts  that  have  been  wet. 

Cover  chest  and  expose  the  right  leg  and  thigh.  Flex  the  leg  and  place 
a  Turkish  towel  under.  Place  another  towel  around  the  upper  thigh  at  the 
groin.  Begin  the  friction  with  the  leg  and  foot;  dip  the  mitts  again  for 
the  thigh.  Treat  in  like  manner  the  left  leg  and  thigh. 

Have  patient  turn  over  and  lie  on  a  pillow  placed  under  the  chest.  Treat 
the  back  in  the  same  manner  as  the  front  of  the  trunk.  To  dry,  cover  the 
entire  back  with  a  Turkish  towel  and  have  patient  hold  the  upper  end  the 
same  as  for  the  chest;  rub  with  downward  strokes  over  the  towel  and  then 
wrap  the  towel  about  the  hand  and  rub  the  surface  again  until  thoroughly 
dry.  Some  prefer  to  begin  the  treatment  with  the  chest  in  cases  of  heart 
disease. 

To  vary  the  severity  and  tonic  effects,  the  temperature  of  the  water  may 


254  TECHNIQUE  OF  HYDROTHERAPY 

be  changed;  more  may  be  left  in  the  mitts  or  the  mitts  dipped  two  or  three 
times  in  treating  each  part,  or  the  friction  given  more  vigorously. 

WET  HAND  RUB 

(W.  H.  R.  or  Whr.) 

The  same  order  and  general  procedure  is  followed  as  for  the  cold  mitten 
friction.  One  part  at  a  time  is  bared,  rubbed  with  the  hand  dipped  in  cold 
water,  followed  by  percussion,  then  dried,  finishing  with  brisk  rubbing 
with  the  dry  towel  and  the  hands.  Dipping  from  two  to  four  or  more 
times  increases  the  tonic  effect. 

COLD  TOWEL  RUB 
(C.  T.  R.  or  Ctr.) 

In  giving  the  cold  towel  rub  a  plain  hand  towel  is  used  instead  of  the  mitts 
employed  for  the  cold  mitten  friction.  The  same  order  is  followed  as  in  the 
two  previous  treatments,  beginning  with  the  arms,  then  the  chest  and 
abdomen,  legs  and  last,  the  back. 

The  arm  is  held  vertically  with  the  palm  toward  the  feet.  The  towel  is 
dipped  in  cold  water  and  wrung  lightly,  quickly  unfolded  and  wrapped 
lengthwise  around  the  arm,  turning  the  upper  corners  into  the  palm  to  be 
grasped  by  the  hand  of  the  patient.  The  part  is  then  rubbed  with  to-and- 
f  ro  movements  outside  of  the  towel.  Percussion  may  also  be  given  to  insure 
a  greater  reaction. 

The  towel  is  now  removed  and  the  arm  dried  as  after  the  cold  mitten 
friction. 

When  the  chest  and  abdomen  are  treated  the  wet  towel  is  spread  out  over 
the  entire  surface  and  the  patient  grasps  the  upper  corners  next  the 
shoulders  and  holds  tightly  while  the  nurse  rubs  with  downward  strokes 
outside  the  towel.  The  other  parts  are  treated  in  a  similar  manner. 

It  should  be  remembered  that  the  cold  towel  rub  takes  more  heat  from 
the  body  than  the  cold  mitten  friction,  and  it  therefore  requires  greater  reac- 
tive ability  on  the  part  of  the  patient.  Because  it  does  abstract  consider- 
able heat  from  the  body,  it  is  often  used  in  fever  as  an  antipyretic  measure. 
By  dipping  the  towel  twice  or  more  for  a  single  part,  its  antipyretic  effects 
are  increased. 

WET  SHEET  RUB 
(W.  Sh.  R.) 

a.  Requisites.      Two  sheets,  two  towels,  a  tub  containing  hot  water  for 
the  feet,  a  pail  of  water  at  60°  to  70°  F.      Other  temperatures  may  be  used 
when  indicated. 

b.  Procedure.     The  patient  should  be  warm  to  begin  with.     Apply  a  cold 
compress  to  the  head.     The  patient  now  stands  in  the  tub  of  hot  water.     A 
sheet  is  wrung  from  cold  water  so  that  it  will  not  drip.       Quickly  wrap  the 
sheet  about  the  patient  as  follows:— 

The  patient  holds  up  both  arms.  The  upper  left  hand  corner  of  the  sheet 
is  placed  under  the  patient's  right  arm;  the  patient  then  lowers  the  right 
arm,  thus  holding  the  corner  of  the  sheet  in  place.  Pass  the  sheet  quickly 


TONIC  FRICTIONS  255 

across  the  front  of  the  body  and  under  the  left  arm,  which  is  lowered. 
The  sheet  should  then  be  carried  across  the  back,  behind  and  up  over  the 
right  shoulder,  then  across  the  chest  and  around  the  neck  over  the  left 
shoulder,  tucking  the  corner  under  the  edge  of  the  sheet  behind.  Now 
tuck  the  sheet  between  the  patient's  legs;  it  is  thus  brought  into  close  con- 
tact with  every  portion  of  the  skin.  Rub  vigorously  and  give  percussion 
over  the  sheet,  covering  the  whole  surface  as  quickly  as  possible  until  the 
sheet  is  thoroughly  warmed.  The  patient  is  not  to  be  rubbed  with  the 
sheet,  but  over  the  sheet.  Two  attendants  are  necessary  to  give  the  best 
results.  Dry  with  a  sheet  and  towels. 

The  wet  sheet  rub  is  a  very  vigorous  tonic  measure.  It  should  not  be 
used  until  the  patient  is  able  to  react  to  the  cold  towel  rub,  the  pail  pour 
and  the  cold  percussion  douche. 

DRIPPING  SHEET  RUB 
(Drip.  Sh.  R.) 

For  the  dripping  sheet  rub  prepare  three  pails  of  cold  water  at  about  70°, 
65°,  60°  F.  respectively.  Proceed  as  with  the  wet  sheet  rub,  using  the 
water  at  70°  from  which  to  wring  the  sheet.  After  the  sheet  and  patient 
are  warmed  by  rubbing  and  percussion,  without  removing  the  sheet  pour 
over  the  shoulders  the  second  pail  of  water,  again  rubbing  vigorously  until 
warm.  Use  the  third  pail  in  like  manner.  Dry  as  after  the  wet  sheet  rub. 
• 

ICE  RUB 

The  order  of  parts  treated  and  the  procedure  in  an  ice  rub  are  substan- 
tially the  same  as  in  the  wet  hand  rub  and  cold  mitten  friction.  In  giving 
the  ice  rub,  however,  it  is  necessary  to  more  thoroughly  protect  the  bed  or 
treatment  table  by  covering  with  oil  cloth  and  towels.  Turkish  towels 
should  be  tucked  closely  about  each  part  so  as  to  absorb  the  water  as  it  runs 
off  the  skin.  The  cake  of  ice  to  be  used  may  be  held  in  the  hand,  or  better 
yet,  wrapped  in  one  or  two  thicknesses  of  gauze. 

The  ice  rub  is  not  much  used  for  general  tonic  purposes,  but  more  fre- 
quently as  an  antipyretic.  When  used  for  this  purpose,  each  part  should 
be  rubbed  for  some  time  and  then  dried  without  friction  or  percussion  with 
the  hands.  Its  prolonged  application  to  the  spine  is  more  decidedly  antipy- 
retic than  the  same  length  of  application  elsewhere.  When  given  in  typhoid 
fever,  the  abdomen  should  be  avoided.  Cold  compresses  should  be  applied 
to  the  head  and  neck  and  also  to  the  heart,  if  necessary. 

SALT  GLOW 

(Sgl.) 

Prepare  about  two  pounds  of  coarse  salt  wet  with  cold  water.  The  treat- 
ment should  be  given  in  a  "wet  room"  or  in  a  bath  tub.  The  patient  stands 
in  a  tub  of  hot  water.  While  standing  at  the  side  of  the  patient  begin  with 
the  arm.  Wet  the  entire  skin  surface  of  the  shoulder,  arm  and  hand  with 
hot  water  from  the  foot  tub.  This  is  done  by  dipping  the  water  with  the 
hands.  Next  apply  the  wet  salt,  spreading  it  evenly  over  the  skin,  now  with 
one  hand  on  each  side  of  the  arm,  rub  vigorously  with  to-and-f ro  movements, 


256  TECHNIQUE  OF  HYDROTHERAPY 

until  the  skin  is  in  a  glow.  Stepping  behind  the  patient  to  the  opposite 
side,  proceed  in  the  same  manner  with  the  other  arm. 

Retain  the  last  position  to  treat  the  front  and  back  of  the  trunk.  With 
one  hand  in  front  and  one  behind,  wet  the  skin  surface  with  hot  water  from 
the  foot  tub.  Now  spread  the  salt  as  before  and  rub  the  entire  skin  surface 
of  the  chest,  abdomen,  shoulders,  back  and  buttocks.  Stepping  behind  the 
patient  and  with  one  hand  under  each  arm,  continue  rubbing  with  the  salt, 
treating  the  sides  of  the  chest,  abdomen  and  the  hips. 

Next  proceed  with  the  legs  in  like  manner.  For  each  limb  have  the 
patient  put  one  foot  on  a  low  stool  so  as  to  bring  the  thigh  about  horizontal. 
Wet  with  water  as  before  and  rub  the  thigh,  leg  and  foot  with  the  wet  salt. 

Finish  the  treatment  by  thoroughly  washing  off  the  salt.  This  may  be 
done  by  a  pail  pour,  shower  or  general  spray.  Dry  with  sheets,  towels  and 
fanning  with  a  dry  sheet  as  from  any  general  wet  treatment. 

If  for  any  reason  the  patient  ought  not  to  stand  so  long,  he  maybe  seated 
on  a  low  stool  while  the  salt  glow  is  given.  Proceed  as  follows: — 

The  patient  sits  on  a  stool  with  the  feet  in  hot  water.  Beginning  with 
the  feet  and  legs,  apply  the  water  and  then  the  salt,  rubbing  briskly  with 
short  strokes,  the  hands  being  on  either  side  of  the  part  treated.  Next 
treat  each  arm  separately;  then  the  chest,  abdomen  and  back  should  be 
rubbed  with  the  wet  salt,  the  attendant  standing  at  the  side  of  the  patient 
with  one  hand  rubbing  the  chest  and  the  other  the  back.  The  patient 
should  stand  while  the  buttocks  and  thighs  are  treated.  Wash  off  the  salt 
and  dry  as  directed  above. 

The  salt  glow  is  a  vigorous  circulatory  stimulant.  Since  no  great  amount 
of  cold  water  is  applied  to  the  body,  it  does  not  require  as  great  reactive 
ability  as  the  wet  sheet  rub  or  cold  douche. 


SPONGING 

Sponging  consists  in  the  application  of  a  liquid  by  means  of  a  sponge,  a 
cloth  or  the  bare  hand,  in  which  the  chief  effect  is  derived  from  the  liquid 
applied.  The  term  ablution  is  also  applied  to  sponging. 

PLAIN  WATER  SPONGING 

(Spg.) 

1.  Hot  Sponge— H.  Spg.    Hot  sponging  has  a  sedative  effect  because  of  the 
slightly  atonic  reaction  which  ensues.     It  is  also  used  to  reduce  fever  where 
chilliness  exists.     When  prolonged  to  40  or  50  minutes  the  temperature  does 
not  rise  as  rapidly  after  the  treatment  as  it  does  following  a  cold  sponge. 

A  large,  soft  sea  sponge  be  may  used,  a  soft  cotton  cloth,  a  wash  cloth  of 
Turkish  toweling,  or  several  thicknesses  of  cheese  cloth.  The  water  should 
be  as  hot  as  can  be  borne.  Bare  one  part  at  a  time  and  treat  in  the  follow- 
ing order:  The  arms,  chest,  abdomen,  legs,  thighs  and  back.  The  cloth  or 
sponge  should  be  dipped  several  times  for  each  part.  Dry  thoroughly. 

2.  Tepid  Sponge— Tepid  Spg.    The  tepid  sponge  has  an  effect  similar  to 
that  of  the  neutral  bath,  i.  e.,  it  is  sedative.     It  may  also  be  used  to  reduce 
fever  but  is  not  as  effective  as  either  the  hot  or  the  cold  sponge. 


SPONGING  257 

3.  Cool  or  Cold  Sponge — C.  Spg.  Cold  sponging  is  much  used  in  the  treat- 
ment of  fever  where  the  skin  is  hot  and  there  is  no  tendency  to  chilliness. 
Each  part  should  be  gone  over  several  times.  The  temperature  of  the 
water  and  the  duration  of  the  treatment  should  be  governed  by  the  effect  to 
be  produced. 

SALLNE  SPONGE 
(Sal.  Spg.) 

About  four  ounces  of  common  salt  are  dissolved  in  a  basin  or  bowl  of 
tepid  water.  The  bare  hand  is  dipped  in  the  salt  water  and  each  part  rub- 
bed lightly. 

The  saline  sponge  has  a  mild  tonic  effect.  Because  of  the  salt  it  stimulates 
the  vasomotors  to  a  greater  extent  than  plain  water. 

ALKALINE  SPONGE 

(Alk.Spg.) 

Use  about  two  ounces  of  bicarbonate  of  soda  to  a  small  basin  of  hot  or 
cool  water  according  to  the  case.  Apply  with  the  bare  hand,  a  soft  cloth  or 
sponge.  The  alkaline  sponge  is  useful  in  itching,  smarting  and  other 
abnormal  sensations.  It  is  usually  applied  only  to  the  part  affected. 

VINEGAR  AND  SALT  RUB 

The  vinegar  and  salt  rub  is  very  useful  in  checking  the  excessive  perpira- 
tion  or  night  sweats  of  phthisis. 

Prepare  a  half  pint  of  equal  parts  of  vinegar  and  water  to  which  add  one 
or  two  tablespoonfuls  of  salt.  Apply  with  the  bare  hand,  drying  lightly 
afterward. 

The  application  should  be  thorough  to  the  parts  that  perspire  the  most; 
other  parts  may  be  gone  over  less  thoroughly. 

ALCOHOL  RUB 
(Ale.  R.) 

The  alcohol  rub  is  frequently  used  following  a  sweating  treatment  instead 
of  the  cold  friction  or  spray.  Its  purpose  is,  of  course,  the  prevention  of 
taking  cold.  Use  one  part  of  alcohol  to  one  part  of  water  (proof  spirit, 
50  per  cent).  Dip  the  hands  in  the  alcohol,  and  rub  each  part,  dipping  the 
second  time  if  needed.  No  drying  with  the  towel  is  necessary. 

WITCHHAZEL  RUB 

(Wzr.) 

The  witchhazel  rub  has  about  the  same  effect  as  the  alcohol  rub.  It  is 
sedative  and  a  mild  astringent.  The  same  procedure  is  used  as  for  the  alco- 
hol rub. 

MENTHOL  RUB 
(Menth.  R.) 

The  application  of  menthol  to  the  skin  gives  a  sensation  of  cold.  The 
effect  is  similar  to  that  of  the  alcohol  rub  or  cold  sponging.  Use  one  ounce 
of  menthol  liniment  (menthol  cryst.  1  oz.,  alcohol  1  pint)  to  three  or  four 
ounces  of  water. 


258  TECHNIQUE  OF  HYDROTHERAPY 

SOAP  WASH 

The  soap  wash  is  used  for  cleansing  the  skin  in  the  case  of  bed  patients. 
Using  a  bowl  of  water  at  102°  F.  with  soap  and  wash  cloth  go  over  each 
part  separately.  With  another  bowl  of  water  at  75°  to  85°  F.  and  another 
cloth,  remove  the  soapy  water  and  dry  thoroughly  with  a  Turkish  towel. 
Each  part  is  gone  over  with  the  soapy  water  followed  by  rinsing  with  plain 
cool  water  and  then  dried  before  the  next  part  is  treated. 


RUBS  AND  FRICTIONS 

These  terms  are  applied  to  procedures  in  which  the  chief  effect  is  derived 
from  friction  with  the  bare  hands. 

CENTRIPETAL  FRICTION 

(C.  F.  or  cf.) 

The  centripetal  friction  consists  principally  of  friction  strokes  from  the 
periphery  toward  the  center.     It  is  designed  to  hasten  the  circulation,,espe- 
cially  in  the  superficial  veins. 
General  Order  of  Movements: — 

1.  Light  to-and-fro  friction — once. 

2.  Apply  lubricant — twice. 

3.  Centripetal  friction — three  times. 

4.  Percussion — twice. 

5.  Stroking  (centrifugal) — three  times. 

Arms 

1.  Beginning  at  finger  tips,  give  light,  quick  to-and-fro  friction  to  the 
shoulder,  being  sure  to  thoroughly  cover  the  whole  surface.      Let  the  hands 
glide  back  as  in  stroking  the  arm. 

2.  Apply  lubricant  with  long  strokes  from  finger  tips  to  shoulder,  return- 
ing with  four  rotary  sweeps.       Give  twice. 

3.  Friction. 
Hand. 

a.  Heavy  centripetal  stroking  to  back  of  hand,  three  times. 

b.  Palm  of  hand  same  as  back  of  hand,  beginning  at  finger  tips.     Fin- 
ish with  double  rotary  movement  in  palm.     Give  three  times. 

Arm  and  forearm. 

a.  Empty  blood  vessels  by  heavy,  even  stroking  from  wrist  to  elbow. 
The  patient's  elbow  rests  on  the  table.      With  one  hand  on  each  side  and 
using  hands  alternately  give  three  movements  with  each. 

b.  Empty   blood  vessels  from  elbow  to  shoulder,  sweeping  well  over 
shoulder.     With  hands  in  the  same  position  and  alternating  as  for  forearm, 
give  three  movements  with  each. 

4.  Percussion.     With  one  hand  on  each  side  of  the  arm,  which  is  held  up 
by    the    patient,    and  with  hands  working  together,  give  percussion  from 
shoulder  to  fingers  and  return.     Give  twice.     Place  the  patient's  arm  on  the 
table  at  his  side,  give  percussion  down  and  up  to  external  surface  as  far  as 
hand. 

5.  Stroking— three  times. 


RUBS  AND  FRICTIONS  259 

Legs 

1.  Leg  flexed  and  foot  flexed.       Placing  one  hand  on  the  sole,  the  other 
on   the   dorsum   of   the   foot,    give  light,  quick,  to-and-fro  friction  trans- 
verse of  foot.      Then  placing  the  foot  flat,  continue  with  rapid  strokes  to 
the  sides  of  the  foot,  the  leg  and  front  of  the  thigh.      Glide  hands  to  knee; 
quick  strokes  to  back  of  thigh;  glide  to  toes. 

2.  Apply  lubricant  with  long  strokes  to  back  of  leg  and  front  of  thigh, 
coming  down  to  knee  with  three  rotary  sweeps,  then  long  strokes  to  back  of 
thigh,  down  with  three  rotary  sweeps  from  knee  to  ankle.     Give  twice. 

_   3.     Friction. 
Foot  (leg  extended). 

a.  Dorsum  with  one  hand — three  times. 

b.  Each  side  with  one  hand,  opposite  hand  supporting  foot;  come  well  up 
back  of  ankle — three  times. 

c.  Sole  with  palm  of  hand — three  times. 

d.  Rotary  strokes  to  heel — three  times. 
Leg  and  thigh  (leg  flexed). 

a.  Calf — empty  blood  vessels  by  heavy,  even  stroking.     Hands  following 
each  other  alternately — three  times  with  each  hand. 

b.  Empty  blood  vessels  under  knee,  hands  alternating — three  times  with 
each. 

c.  With  one  hand  on  knee  to  support  leg,  give  heavy  stroking  to  front  of 
leg,  beginning  at  toes — three  times. 

d.  Rotary  to  knee,  hands  working  together — three  times. 

e.  Empty  blood  vessels  of  thigh,    beginning   with   posterior   surface, 
hands  working  together — three  times. 

f.  Anterior  thigh — three  times. 

4.  Percussion.      With  one  hand  on  each  side  give  percussion  from  hip  to 
ankle,  down  and  up — give  twice. 

5.  Stroking— three  times. 

Chest  and  Abdomen 

1.  Making   the  hands  work  together,  stroke  the  neck  downward  three 
times  and  give  rotary  movements  as  follows:     Three  above  the  clavicle  and 
to  shoulder;  six  from  below  clavicle  to  level  of  elbow,   (i.  e.,  nine  down  each 
side) ,  returning  up  over  median  part  of  abdomen  and  chest.       Give  once  or 
twice. 

2.  Apply  lubricant  with  long  strokes  up  center,  four  rotary  sweeps  down 
sides,  covering  whole  surface  thoroughly.      Give  twice. 

3.  Friction. 

a.  Empty  blood  vessels  of  neck  and  shoulders  by  stroking  from  back  of 
ears  downward  to  chest  and  shoulders — three  times. 

b.  Give  strokes  from  shoulders  to  median  line  over  the  pectorals — three 
times. 

c.  Using  the  thumb  and  thenar  surface,  give  heavy  stroking  outward 
from  median  line  over  ribs  and  abdomen — about  six  times,  advancing  toward 
the  pubes. 

d.  Stroking  from  umbilicus  outward  and  downward  toward  middle  of 
Poupart's  ligament — three  times. 


260  TECHNIQUE   OF  HYDROTHERAPY 

4.  Percussion  up  and  down  left  side,  the  same  on  right  side,  give  twice. 

5.  Stroking — three  times. 

Back 

1.  Light  friction  with  the  full  hand  down  spine,  hands  alternating — three 
times    each.      To-and-fro    friction,    beginning    well   up    on  neck,  covering 
shoulders,  back  and  hips.     Give  three  times. 

2.  Apply  lubricant  with  long  strokes  up  spine,  four  rotary  sweeps  down 
sides — twice. 

3.  Friction. 

a.  Heavy  friction  with  full  hand  down  spine — hands  alternating,  each 
three  times. 

b.  Heavy  rotary,  full  sweep  to  shoulders— three  times. 

c.  From  shoulders  down,  across  arms  stroking  toward  spine,  following 
ribs — six  times. 

d.  Lower  back,  heavy  friction  upward  over  buttocks  toward  spine — three 
times.      Upward  on  hips— three  times.      Outward,  using  thumb  and  thenar 
surface  over  crest  of  ilium — three  times. 

4.  Percussion  up  and  down  on  left  side,  same  on  right  side.     Give  twice. 

5.  Stroking. 

a.  Full  sweeps  covering  back — three  times. 

b.  Slow  strokes  with  full  hand  down  spine — six  times. 

OIL  RUB 

(O.  R.) 

The  oil  rub  softens  the  skin  and  is  frequently  used  as  a  protective  after 
sweating  treatments.  It  may  be  given  in  the  same  manner  as  the  centrip- 
etal friction,  omitting  procedure  number  one,  light  friction  and  procedure 
number  four,  percussion.  If  desired,  the  following  abbreviated  method  may 
be  used,  always  omitting  the  percussion  after  hot  treatments. 

General  Order: — 

1.  Apply  lubricant. 

2.  Rotary  friction. 

3.  Percussion. 

4.  Stroking  (centrifugal) . 

Arms 

1.  Apply  lubricant,  beginning  at  hands  with  a  long  stroke,  go  over  the 
arm  up  to  the  shoulder — three  times. 

2.  Beginning  at  hand,  apply  long  stroke  up  to  shoulder,  returning  with 
alternate  rotary  movements,  three  each  to, — shoulder,  arm,  elbow,  forearm, 
wrist  and  hand— three  times. 

3.  Percussion   up  and  down  twice  on  external  surface.       Give  same  on 
inner  surface.     Six  percussion  strokes  to  the  hand. 

4.  Finish  with  long  strokes  from  shoulder  to  finger  tips— three  times. 

Legs 

1.  Beginning  at  foot,  apply  lubricant  with  long  strokes  up  to  hip  with 
both  hands,  covering  the  entire  surface — three  times. 


RUBS  AND  FRICTIONS  261 

2.  Apply  long  strokes  from  foot  to  knee,  returning  with  alternate  rotary 
movements,  three  each  to, —knee,  calf,  ankle  and  foot — twice.      Return  to 
hip  with  long  stroke.      With  hands  on  anterior  surface  of  thigh,  from  hip 
to  knee,  give  eight  or  ten  rapid  alternate  rotary  friction  movements.     Give 
the  same  on  the  posterior  surface  of  the  thigh— three  times.     Continue  with 
rotary  friction  from  knee  down  as  at  first — once. 

3.  Percussion  same  as  arm. 

4.  Long  stroking  movement  from  hip  to  toes — three  times. 

Chest  and  Abdomen 

1.  Lubricate,  with  hands  working  together,  begin  at  median  line  below, 
going  lightly  up  the  median  line  and  down  the  sides — three  times. 

2.  Hands  working  together,  stroke  the  neck  downward  three  times,  then 
give  rotary  movements  three  each, — above  clavicle,  to  shoulder  below  clavicle, 
nine  down  each  side,  nine  up  over  median  part  of  abdomen  and  chest — three 
times. 

3.  Have  patient  take  and  hold  a  deep  breath.       Beginning  well  over  at 
lower    left  side,  give  percussion  up  that  side  to  top  of  shoulder,  down  on 
same  side  of  median  line,  up  on  right  side  of  median  line  to  top  of  shoulder, 
and  down  the  right  side — twice. 

4.  Stroking — movement  same  as  in  lubricating — three  times. 

Back 

Procedure  the  same  as  for  the  chest.  Finish  with  six  long,  gentle,  down- 
ward strokes  to  spine. 

TALCUM  RUB 
(Talc.  R.) 

The  talcum  rub  is  useful  where  oil  is  objectionable,  as  in  warm  weather 
or  where  there  is  a  tendency  to  too  free  perspiration  after  treatment.  It 
dries  rather  than  softens  the  skin.  It  is  also  useful  in  hives,  and  should  be 
given  after  a  prolonged  cool  bath.  The  procedure  is  the  same  as  with  the 
oil  rub. 

DRY  FRICTION 
(I).  F.) 

The  procedure  for  dry  friction  or  the  dry  hand  rub  (d.  h.  r.)  is  the  same 
as  for  the  oil  rub  except  that  no  lubricant  is  used.  If  given  briskly  with 
vigorous  to-and-fro  friction  and  followed  by  percussion,  the  effect  is  to 
quicken  the  circulation  in  the  skin  and  warm  the  surface.  The  treatment 
also  stimulates  heat  production. 

Slow,  heavy  friction  without  percussion,  as  to  spine,  forehead,  etc.,  is  sed- 
ative. 


BATHS 

Various  procedures  more  or  less  similar  and  commonly  called  baths  are 
included  under  this  head. 


262  TECHNIQUE  OF  HYDROTHERAPY 

I.  PARTIAL  IMMERSION  BATHS 
HAND  AND  ARM  BATH 

The  hand  and  arm  may  be  immersed  in  neutral,  hot  or  cold  water,  or  the 
two  latter  alternately.  For  this  purpose  employ  a  foot  tub  (better  one  of 
elliptical  shape)  with  sufficient  water  to  immerse  the  hand  and  forearm  to 
the  elbow,  or  including  the  elbow.  Very  deep  pails  may  be  used.  When 
hot  water  is  used,  it  should  be  as  hot  as  can  be  borne.  Immersion  of  the 
hands  in  cold  water  is  useful  in  controlling  epistaxis. 

To  give  hot  and  cold  immersion  to  an  infected  hand  or  arm  (blood  poison- 
ing) employ  two  pails  or  tubs,— one  of  the  hottest  water  that  can  be  borne, 
and  the  other  of  ice  water  with  a  block  of  ice  in  it.  To  the  cold  water  may 
be  added  one-fourth  or  one-half  dram  of  crystals  of  permanganate  of  potas- 
sium, and  to  the  hot  water  about  five  times  this  quantity  of  oxalic  acid. 
Immerse  the  hand  and  arm  in  hot  water  for  one  and  one-half  to  two  minutes, 
then  in  the  cold  for  fifteen  to  thirty  seconds.  Continue  these  alternations 
for  twenty-five  minutes  to  an  hour,  finishing  with  the  cold.  Hot  water 
should  be  added  to  the  tub  as  fast  as  can  be  borne.  The  procedure  should 
be  repeated  from  one  to  four  times  daily  as  indicated.  Other  parts  of  the 
body,  as  the  foot,  may  be  treated  in  a  similar  manner.  Massage  is  strictly 
countra-indicated  in  infected  conditions. 

FOOT  BATH 
(Ft.  B.) 

The  foot  bath  is  one  of  the  most  useful  measures  in  hydrotherapy.  Its 
chief  use  is  as  a  preliminary  or  adjunct  to  other  treatment.  It  may  be 
given  with  the  patient  lying  or  sitting,  and  is  sometimes  given  with  the 
patient  standing.  Large  pails  may  be  used,  but  more  conveniently  tubs  of 
an  elliptical  shape  about  sixteen  inches  long  and  eight  to  ten  inches  deep. 

If  the  foot  bath  is  given  in  bed  or  on  a  treatment  table,  protect  the  bed- 
ding or  table  coverings  with  an  oil  cloth.  Protect  the  patient  with  a  blanket 
or  sheet,  covering  the  knees  and  the  foot  tub.  Tuck  this  covering  about  the 
limbs  and  foot  tub  so  as  to  prevent  the  circulation  of  air.  When  the  feet 
are  taken  out  of  the  water,  dry  them  thoroughly,  especially  between  the 
toes,  and  immediatly  cover  well  with  dry  coverings  or  put  on  slippers. 

1.  Hot  Foot  Bath — H.  ft.  B.       The    water  should  rise  above  the  ankles. 
The  bath  may  be  at  a  temperature  of  about  105°  F.,  and  should  be  gradually 
increased  as  fast  as  can  be  borne  to  a  maximum  of  about  120°  F.     It  may  be 
continued  from  five  minutes  to  half  an  hour.      At  the  close  the  feet  should 
receive  a  pour  or  dash  of  cold  water  and  be  thoroughly  dried. 

It  is  often  necessary  to  use  the  cold  head  compress  if  the  bath  is  very 
hot,  continued  for  a  long  time,  or  if  given  with  the  patient  sitting  up,  and 
in  all  cases  where  there  is  a  tendency  to  faintness. 

Effects.  The  hot  foot  bath  is  an  efficient  means  of  securing  a  derivative 
effect.  It  draws  blood  from  all  other  parts,  especially  those  that  are  con- 
gested. The  cold  pour  or  douche  given  at  the  close  helps  to  maintain  the 
blood  in  the  feet.  It  is  sometimes  desirable  to  use  a  mustard  foot  bath,  in 
which  case  add  three  or  four  tablespoonfuls  of  mustard  to  the  water. 

2.  Cold  Foot  Bath — C.  ft.  B.      The    water    should  be  from   two  to  four 


BATHS  263 

inches  deep  at  a  temperature  of  45°  to  60°  F.  The  feet  should  be  previously 
warmed  and  during  the  bath,  rubbed  with  the  hands  or  one  foot  by  the  other. 
Duration,  one  to  five  minutes. 

Effects.  The  shallow  cold  foot  bath  causes  reflex  contraction  of  the  blood 
vessels  of  the  brain,  pelvic  organs  and  liver;  also  contraction  of  the  muscles 
of  the  uterus,  bladder,  stomach  and  intestines.  The  cold  foot  bath  should 
not  be  given  during  the  menstrual  period  or  in  case  of  acute  pulmonary, 
abdominal  or  pelvic  inflammation. 

3.  Alternate  Hot  and  Cold  Foot  Bath— H.  &  C.  ft.  B.  Use  two  tubs  of  water 
deep  enough  to  well  cover  the  ankles,  one  as  hot  as  can  be  borne  (tempera- 
ture gradually  raised)  and  the  other  at  45°  F.  Immerse  the  feet  in  the  hot 
water  for  two  minutes  and  in  the  cold  fifteen  to  thirty  seconds.  Continue 
alternations  for  ten  to  fifteen  minutes,  wiping  from  the  cold. 

Effects.  The  alternate  hot  and  cold  foot  bath  produces  powerful  fluxion 
effects  in  the  feet.  For  this  reason  the  derivation  secured  by  its  use  is  very 
decided  and  enduring.  It  is  especially  useful  in  congestive  headache,  in  which 
case  it  is  well  to  apply  a  cold  compress  to  the  head  or  head  and  neck  at  the 
same  time.  It  is  also  useful  in  treating  infections  of  the  foot,  Charcot's  joint 
at  the  ankle,  tuberculosis  of  the  ankle  or  bones  of  the  foot  and  in  gangrene 
to  hasten  the  production  of  the  line  of  demarkation. 

LEG  BATH 
(Lg.  B.) 

For  the  leg  bath  a  tub  should  be  provided  deep  enough  to  immerse  the  legs 
to  the  knees.  If  used  in  the  treatment  room  the  tub  should  be  fitted  with 
an  outlet  at  the  base  so  as  to  obviate  the  necessity  of  tipping  the  tub  over 
to  empty  it.  It  should  be  placed  near  or  against  the  wall  so  that  it  may  be 
filled  from  a  hot  and  a  cold  wall  faucet  by  two  short  rubber  hose.  Also  pro- 
vide a  stool  an  inch  or  two  higher  than  the  tub. 

The  patient  should  be  covered  with  a  sheet  or  blanket  and,  if  the  room  is 
not  warm  enough,  a  large  fomentation  cloth  or  Turkish  towel  placed  over  the 
knees.  If  necessary,  place  a  doubled  fomentation  cloth  under  the  knees 
over  the  rim  of  the  tub. 

1.  Hot  Leg  Bath— H.  Ig.  B.  Begin  with  the  water  at  103°  F.  and  increase 
the  temperature  as  rapidly  as  can  be  borne.  Use  cold  cephalic  and  cervical 
compresses  (or  ice  bags)  and  renew  before  they  are  warmed.  In  case  the 
leg  bath  is  combined  with  other  hot  treatment,  as  fomentations  to  the  spine, 
it  may  be  necessary  to  use  an  ice  bag  over  the  heart,  especially  if  the  treat- 
ment is  continued  to  profuse  perspiration.  The  treatment  should  be  con- 
tinued in  a  given  case  until  the  desired  effect  is  produced.  This  may  require 
from  five  to  thirty  minutes  according  to  conditions  and  the  particular  effect 
desired.  Finish  with  a  cold  dash  to  the  legs. 

Effects.  The  hot  leg  bath  is  a  much  more  powerful  derivative  measure 
than  the  hot  foot  bath  and  is  one  of  the  best  treatments  that  can  be  used  for 
this  purpose.  When  combined  with  fomentations  to  the  spine  or  chest,  and 
especially  when  the  patient  drinks  some  hot  liquid  at  the  same  time,  very 
profuse  perspiration  is  produced.  If  used  in  the  home  such  a  sweating  trea- 
ment  should  be  concluded  by  a  cold  mitten  friction  or,  if  given  in  the  treat- 


264  TECHNIQUE  OF  HYDROTHERAPY 

ment  room,  by  a  graduated  or  alternate  hot  and  cold  shower  and  spray.     The 
pail  pour  is  also  sometimes  used  for  the  same  purpose. 

2.  Alternate  Hot  and  Cold  Leg  Bath— H.  &  C.  Ig.  B.  The  procedure  is  the 
same  as  with  the  alternate  foot  bath.  It  is  necessary  to  apply  a  cold  com- 
press to  the  head  and  often  an  ice  bag  to  the  heart. 

Effects.  The  alternate  hot  and  cold  leg  bath  produces  most  powerful  flux- 
ion in  the  legs  and  feet.  It  is  especially  useful  in  treating  edema  of  these 
parts  whether  due  to  heart  or  kidney  disease.  After  two  or  three  treat- 
ments have  been  given,  pieces  of  ice  should  be  added  to  the  cold  water. 
The  treatment  may  be  followed  by  heavy  centripetal  friction  to  the  feet 
and  legs. 

SITZ  BATH 

(Z.) 

For  the  sitz  bath  a  porcelain  sitz  tub  with  special  inlet  and  outlet  is  the 
most  satisfactory;  one  of  metal  or  an  ordinary  wash  tub  may  be  used.  In 
addition  there  should  be  a  foot  tub  for  immersion  of  the  feet  in  hot  water. 
Also  a  pail  of  cold  water  with  a  hand  towel  for  keeping  the  head  cool. 

Protect  the  patient  from  contact  with  the  tub  by  towels  or  fomentation 
cloths  placed  behind  the  back  and  under  the  knees.  Cover  £he  patient  with 
a  blanket  or  sheet.  The  temperature  of  the  foot  bath  should  be  at  least 
two  or  three  degrees  above  that  of  the  sitz  bath. 

1.  Cold  Sitz  Bath — C.  Z.      Sufficient  water  should  be  used  to  cover  the 
hips  and  come  up  on  the  abdomen.     Temperature— 55°  to  75°  F.     Foot  bath — 
105°  to  110°  F.     Time — one  to  eight  minutes.     Rub  the  hips  to  promote  reac- 
tion.     Friction  mitts  may  be  used.     If  desired,  the  water  may  be  flowing. 
It  adds  somewhat  to  the  effect. 

Effects.  If  of  brief  duration — two  to  four  minutes,  it  greatly  stimulates 
the  pelvic  circulation  and  the  musculature  of  the  bowels,  bladder  and  uterus. 
When  given  with  very  cold  water  (55°  to  65°)  and  vigorous  friction  (cold 
rubbing  sitz  bath)  these  effects  are  intensified.  The  cold  rubbing  sitz  bath 
is  very  useful  in  constipation,  in  subinvolution  and  in  hastening  the  absorp- 
tion of  residual  thickening  after  pelvic  inflammations.  With  the  tempera- 
ture somewhat  modified,  it  may  be  used  in  children  in  treating  nocturnal 
enuresis. 

2.  Prolonged  Cold  Sitz  Bath-C.  Z.    Temperature— 70°  to  85°  F.     Time- 
fifteen  to  forty  minutes.     Foot  bath — 105°  to  110°  F.     This  may  be  begun  at  a 
higher  temperature  and  very  gradually  lowered  to  the  desired  point  (gradu- 
ated sitz  bath).       It  should  not  at  any  time  cause  chilliness  and  rubbing  is 
not  desirable.       If  necessary  to  give  a  sensation  of  warmth,  a  fomentation 
or  wrapped  spinal  hot  water  bottle  may  be  applied  to  the  spine. 

Effects.  The  prolonged  cold  sitz  bath  causes  extreme  and  lasting  contrac- 
tion of  the  pelvic  blood  vessels  and  of  the  muscular  wall  of  the  uterus.  It 
is  therefore  very  useful  in  subinvolution. 

:J.  Neutral  Sitz  Bath— Neut.  Z.  Temperature— 92°  to  97°  F.  Footbath— 
102C  to  106°  F.  Apply  cool  compress  to  the  head.  Time— twenty  minutes 
to  one  or  two  hours.  Effect— sedative. 

4.     Very  Hot  Sitz  Bath— H.  Z.    Begin  at  a  temperature  of  about  100°  F.  and 


BATHS  265 

rapidly  increase  to  106°  to  115°  F.  Foot  bath— 110°  to  120°  F;  it  should  be  kept 
at  least  2°  hotter  than  the  temperature  of  the  sitz  bath.  Keep  the  head 
cool  by  cold  cephalic  and  cervical  compresses.  Duration — three  to  eight 
minutes.  At  the  close  cool  the  bath  to  neutral  for  one  to  three  minutes. 
If  sweating  has  been  produced,  pour  cold  water  over  the  shoulders  and  chest. 

Effects.  The  hot  sitz  bath  is  used  to  relieve  dysmenorrhoea  and  pelvic  pain 
from  various  other  causes.  It  is  very  valuable  in  both  acute  and  chronic  cys- 
titis, hypertrophy  of  the  prostate  and  acute  retention  of  urine  due  to  pros- 
tatic  hypertrophy.  It  is  also  useful  in  amenorrhoea  due  to  pelvic  anemia, 
in  sciatica  and  helpful  in  reducing  femoral  or  inguinal  hernia.  For  reduc- 
ing hernia  the  temperature  should  not  be  lowered  at  the  close. 

5.  Revulsive  Sitz  Bath — Rev.  Z.  Begin  at  a  temperature  of  100°  F.  and 
increase  rapidly  to  106°  to  115°  F.  Foot  bath— 110°  to  120°  F.  Keep  the  head 
cool  by  cold  cephalic  and  cervical  compresses.  Duration — three  to  eight 
minutes.  Finish  by  a  cold  pail  pour  to  the  hips;  temperature  of  the  water — 
55°  to  65°  F. 

Effects.  The  revulsive  sitz  produces  a  fluxion  effect  in  the  surface  and 
deep  blood  vessels.  It  is  one  of  the  most  useful  measures  in  treating 
chronic  inflammatory  conditions  in  the  pelvic  viscera  such  as  various  forms 
of  salpingitis,  ovaritis,  cellulitis,  prostatitis,  prostatic  hypertrophy,  etc. 

,HOT  HALF  BATH 
(H.    1-2  B.) 

The  hot  half  bath  is  given  in  a  full  length  bath  tub.  Fill  the  tub  with 
water  at  100°  to  102°  F.  and  deep  enough  to  reach  the  patient's  navel  when 
the  patient  is  sitting.  The  patient  now  sits  down  in  the  tub  with  the 
shoulders  covered  by  a  sheet  and  the  head  kept  cool  by  a  cold  wet  towel. 
It  is  usually  best  to  apply  this  just  before  the  patient  enters  the  bath.  The 
temperature  of  the  bath  is  gradually  raised  to  108°  or  110°  F,  and  continued 
for  three  to  eight  minutes.  If  necessary,  an  ice  bag  should  be  used  over 
the  heart.  Conclude  the  treatment  by  a  cold  pail  pour  to  the  hips. 

The  effects  and  uses  are  the  same  as  those  of  the  revulsive  sitz.  This 
treatment  must  not  be  confused  with  the  shallow  bath  which  is  given  with 
cold  water,  and  is  a  tonic  measure. 

II.  FULL  IMMERSION  BATHS 

The  tub  used  for  general  or  full  immersion  baths  should  be  long  enough 
so  that  the  body  may  be  completely  immersed, — a  6-foot  tub  for  men,  in 
many  cases  a  5^-foot  tub  is  long  enough  for  women.  The  head  should  rest  on 
an  air  pillow  or  small  invalid  ring,  and  for  emaciated  patients,  a  folded  sheet 
placed  under  the  nates.  In  a  hot  bath,  the  head  must  be  kept  cool  by  a  cold 
compress.  In  the  case  of  full  tub  baths  it  is  especially  necessary  that  the 
temperature  of  the  water  be  tested  by  means  of  a  thermometer.  In  order- 
ing tub  baths,  the  desired  temperature  should  be  specified  on  the  prescrip- 
tion. 

PLAIN  TUB  BATHS 

1.  Hot  Tub  Bath— H.  B.  or  H.  Tub.  Temperature— 100°  to  106°  F.  Time- 
two  to  twenty  minutes.  Give  cold  water  to  drink  freely.  Keep  the  head 


266  TECHNIQUE  OF  HYDROTHERAPY 

cool.  If  necessary,  apply  an  ice  bag  to  the  heart  and  the  back  of  the  neck. 
It  is  usually  best  to  begin  the  bath  at  about  98°,  gradually  raising  the  tem- 
perature to  the  desired  point.  The  treatment  may  be  finished  by  cooling 
the  bath,  or  by  a  cold  pour  or  shower  given  immediately  after  rising  from 
the  bath. 

Effect.  The  effect  varies  according  to  the  temperature  and  duration  of 
the  bath.  If  much  prolonged  or  the  temperature  very  high,  profuse  sweat- 
ing is  produced.  The  hot  tub  bath  may  be  used  as  a  preparation  for  cold 
treatment.  A  warm  bath  at  100°  to  102°  is  very  effective  in  relieving  opis- 
thotons  in  tubercular  meningitis  and  is  also  beneficial  in  other  diseases 
associated  with  spasticity  of  the  muscles. 

2.  Neutral  Bath— Neut.  B.  Temperature— 94°  to  97°  F.  Time— fifteen 
minutes  to  three  or  four  hours;  usually  twenty  to  thirty  minutes.  Wet  the 
forehead  and  face  in  cool  water.  Cool  the  bath  2°  or  3°  just  at  the  close. 
Dry  the  patient  with  a  sheet  directly  from  the  bath,  Use  no  percussion  or 
unnecessary  rubbing  as  this  destroys  the  sedative  effect. 

Effects.  The  neutral  bath  is  given  for  sedative  purposes.  To  accomplish 
this  it  must  exert  a  relaxing  effect  and  so  equalize  the  circulation  as  to 
reduce  the  amount  of  blood  in  the  brain  and  spinal  cord.  Its  temperature 
will  therefore  vary  with  the  condition  of  the  patient,  especially  as  regards 
the  skin  temperature.  The  season  of  the  year  must  also  be  taken  into 
account.  For  these  reasons  it  may  frequently  be  necessary  to  employ  the 
upper  limit  of  the  neutral  temperatures  or  raise  the  bath  to  98°  or  even  99°. 
The  air  of  the  bath  room  should  be  warm,  and  if  the  bath  is  much  prolonged, 
stretch  a  sheet  over  the  tub.  The  cooling  of  the  water  2°  or  3°  just  at  the 
close  is  usually. necessary  to  prevent  the  slight  sensation  of  chilliness  which 
is  likely  to  be  produced  by  contact  with  the  air  on  emerging  from  the  bath. 
When  used  for  insomnia,  it  should  be  given  just  previous  to  retiring. 

;$.  Cold  Bath— C.  B.  or  C.  Tub.  Temperature— 55°  to  90°  F.  Time— a 
plunge  only,  to  twenty  or  more  minutes,  depending  on  the  temperature  and 
effect  desired.  It  is  necessary  to  employ  rubbing  constantly  or  at  frequent 
intervals.  The  patient's  face  should  be  bathed  in  cold  water  before  enter- 
ing the  bath,  and  it  is  imperative  that  the  skin  be  warm  before  the  bath  is 
given. 

Effects.  When  given  to  a  patient  with  a  normal  temperature  and  lasting 
for  a  few  seconds  or  minutes  only,  the  effect  is  that  of  a  stimulant  and  tonic. 
The  cold  rubbing  bath  is  the  most  commonly  employed  method  of  treating 
typhoid  fever  in  institutions  where  tubs  are  available  and  convenient  to  use. 
The  strict  Brand  bath  is  too  severe  a  measure  for  many  patients.  The 
methods,  indications  for  and  the  precautions  in  the  use  of  the  cold  bath 
have  been  very  fully  discussed  under  the  treatment  of  typhoid  fever,  q.  v. 

4.  Brand  Bath.  As  advised  by  Brand  for  the  treatment  of  typhoid  fever 
the  procedure  is  as  follows:— 

Temperature— 65°  to  70°  F.  Bathe  the  face  and  head  in  cold  water  or  ice 
water.  Lift  the  patient  into  the  bath.  He  should  be  rubbed  constantly  to 
keep  the  blood  in  the  skin.  If  chilling  can  not  be  prevented  by  vigorous 
rubbing,  the  patient  must  be  removed  from  the  bath.  Time — fifteen  min- 
utes. Repeat  when  the  temperature  reaches  102.5°  or  103°  F.  Effect — 
antipyretic. 


BATHS  267 

5.  Graduated  Bath— Grad.  B.    The  graduated  bath  is  as  efficient  in  lower- 
ing febrile  temperature  when  much  prolonged  and  is  less  objectionable  to  the 
patient  than  the  Brand  bath.     As  the  bath  is  frequently  used  in  typhoid,  the 
patient  should  be  made  comfortable  by  an  air  pillow  and  hammock,  made  by 
tying  a  sheet  across  the  tub,  fastening  the  corners  and  sides  underneath. 
Temperature — begin  at  98°  or  above,  depending  on  the  height  of  the  fever, 
i.  e.,  from  3°  to  5°  lower  than  the  mouth  temperature.     The  skin  must  be 
warm  to  begin  with.     Apply  cold  compresses  to  the  head.     Gradually  reduce 
the  temperature  of  the  bath  to  about  85°  F;  when  below  90°  F.  or  if  the 
patient  feels  chilly  or  shpws  goose  flesh,  he  should  be  rubbed  constantly  to 
keep  the  blood  in  the  skin,  and  so  prevent  or  overcome  chilling.     A  spine 
bag  filled  with  hot  water  may  be  laid  along  the  spine  for  the  same  purpose. 
Both  pulse  and  temperature  should  be  closely  watched  during  the  bath.     The 
temperature    of  the  patient    should  be  taken  every  12  or  15  minutes.     On 
removal,  immediately  wrap  the  patient  in  a  sheet,  drying  quickly,  and  if 
there  is  goose-flesh  or  chilliness,  rub  briskly  with  the  hands  until  the  blood 
returns  to  the  skin.     If  very  cyanotic,  put  the  patient  into  a  hot  blanket 
pack  for  a  few  minutes  and  take  him  out  with  a  cold  mitten  friction.     Effect — 
tonic  chiefly  or  antipyretic  according  to  the  condition  in  which  it  is  given. 

6.  Cold  Shallow  Bath — C.  S.  B.     Fill  the  tub  four  to  six  inches  deep  with 
water  at  65°  to  75°  F.     The  patient's  feet  should  be  warm  before  entering, 
and  the  head  kept  cool  by  cold  wet  towels.     The  patient  sits  down  in  the 
cold  water  and  rubs  the  arms,  legs  and  chest  vigorously  while  the  attendant 
rubs  the  hips  and  back.     Cold  water  dipped  from  the  tub  is  dashed  over  the 
shoulders  and  back,  and  these  parts  are  again  rubbed.     The  patient  now  lies 
down  in  the  bath  and  rubs  the  chest  and  abdomen,  while  the  attendant  rubs 
the  legs.     This  procedure  may  be  repeated  once  or  twice  if  desired. 

The  entire  treatment  should  last  from  two  to  four  minutes,  and  on  emerg- 
ing from  the  bath,  the  skin  surface  should  be  in  a  decided  glow,  otherwise 
the  proper  effect  has  not  been  obtained.  The  cold  shallow  bath  is  one  of  the 
most  vigorous  tonic  measures  employed  in  hydrotherapy. 

HYDRO-ELECTRIC  BATHS 

In  giving  the  hydro-electric  or  electrothermal  bath  a  neutral  temperature 
is  usually  employed.  The  patient  is  completely  immersed  in  the  water  with 
the  head  on  an  air  pillow  and  kept  cool  by  a  cold  wet  towel.  The  elec- 
trodes should  hang  from  the  side  of  the  tub,  so  they  may  be  placed  in  any 
desired  position  along  the  sides  or  at  the  feet  of  the  patient.  The  treat- 
ment is  begun  with  one  electrode  at  the  feet  and  the  other  near  the  arm  on 
the  opposite  side.  The  electricity  is  turned  on  to  comfortable  tolerance. 
Time — five  to  twenty  minutes.  After  half  the  time  has  expired  the  elec- 
trode should  be  reversed,  the  one  at  the  foot  of  the  tub  being  brought  up 
along  the  arm  of  same  side,  and  the  other  near  the  opposite  arm,  being 
placed  at  the  foot  on  the  same  side.  These  directions  do  not  apply  to  the 
galvanic  bath.  In  using  galvanism  the  positive  pole  should  be  placed  at  the 
head,  preferably  dipping  into  the  water  underneath  the  pillow,  and  the 
negative  pole  at  the  feet. 

Precautions.  To  avoid  shock  there  should  be  no  current  passing  when  the 
patient  steps  in  or  out.  Be  sure  all  appliances  are  in  good  order  before 


268  TECHNIQUE  OF  HYDROTHERAPY 

the  patient  enters  the  bath.  Keep  all  parts  of  the  generator,  switches, 
rheostat,  etc.  absolutely  dry  and  clean.  Do  not  handle  the  switches  or  the 
rheostat  with  wet  hands. 

Do  not  start  or  stop  the  motor  generator  or  turn  the  current  on  or  off 
while  the  rheostat  is  turned  on.  After  the  patient  enters  the  bath,  the  cur- 
rent switch  is  turned  on  and  the  motor  or  generator  started;  next  gradually 
increase  the  current  by  turning  the  rheostat.  Before  the  patient  leaves  the 
bath  turn  off  the  current  by  reversing  these  steps,  i.  e.,  first  gradually  lessen 
the  current  by  turning  down  the  rheostat  then  stop  the  generator  and  turn 
off  the  switch. 

1.  Faradic  Tub    Bath— Neut.  Farad.      The  induction    coil  used  should  be 
large  enough  to  amply  supply  any  current  strength  needed  and  the  inter- 
rupter so  arranged  as  to  give  any  desired  rate  of  vibration,  at  least  both 
slow  and  rapid  interruptions  should  be  provided  for. 

Effects.  Slow  or  medium  f aradic  for  five  or  six  minutes  is  stimulating  and 
tonic.  It  is  beneficial  in  flaccid  paralysis  and  in  general  atonic  conditions  of 
the  muscular  system.  Rapid  faradic,  given  with  less  current  strength  and 
continued  for  twelve  or  fifteen  minutes  is  sedative.  The  faradic  tub  bath 
is  less  satisfactory  than  the  sinusoidal  as  the  alternations  of  the  current  are 
sharp  and  therefore  less  agreeable  to  the  patient. 

2.  Sinusoidal  Tub  Bath — Neut.  Sinu.     For  the  production  of  a  sinusoidal 
current  the  sinusoidal  dynamo  devised  by  Kellogg  is  the  most  satisfactory. 
The  slow  sinusoidal  current  gives  a  maximum  muscular  contraction  with  a 
minimum  of   unpleasantness.     The    contraction  of  the  muscles  is  vigorous 
and  painless. 

Effects.  The  slow  sinusoidal  for  five  or  six  minutes  is  stimulating  and 
tonic.  Rapid  sinusoidal  for  a  longer  time  is  sedative.  The  slow  sinusoidal 
is  useful  in  all  forms  of  flaccid  paralysis,  atrophied  muscles,  weak  abdomi- 
nal muscles,  splanchnoptosis,  etc.  It  is  much  more  agreeable  to  the  patient 
and  more  efficient  than  faradic  electricity,  and  for  these  reasons  should 
replace  the  faradic  wherever  possible. 

',}.  (ialvanic  Tub  Bath — Neut.  Galv.  Unless  given  from  a  battery  of  cells 
or  a  small  dynamo  not  connected  with  alighting  system,  galvanic  electricity 
is  dangerous.  Even  then  burns  may  result  if  carelessly  used.  Its  adminis- 
tration should  not  be  entrusted  to  a  nurse  unless  specially  trained  in  the  tech- 
nique and  possessing  the  requisite  knowledge  of  the  physics  of  the  galvanic 
current.  Moreover  the  effects  usually  sought  from  the  galvanic  tub  bath 
may  be  obtained  in  other  ways  without  risk  to  the  patient. 

Precautions.  In  the  use  of  the  galvanic  tub  bath  all  the  precautions  men- 
tioned above  should  be  carefully  observed.  The  current  must  never  be 
turned  on  before  the  patient  enters,  and  always  be  turned  off  before  he  steps 
from  the  bath.  If  this  is  not  done  a  severe  shock  may  be  occasioned  as  the 
patient  places  one  foot  in  the  bath  with  the  other  on  a  wet  floor,  thus  mak- 
ing a  grounding  contact  through  a  cement  floor  or  worse  yet  through  some 
metal  pipe  near  by. 

Always  ascertain  the  polarity  before  the  electrodes  are  placed.  To  do  this, 
place  the  electrodes  in  water  an  inch  or  two  apart  and  turn  the  current  on. 
The  bubbles  formed  at  the  negative  pole  are  larger  and  more  numerous 


BATHS  269 

than  those  formed  at  the  positive  pole.  Place  the  positive  pole  at  the  head 
of  the  tub  and  the  negative  at  the  foot.  Be  sure  that  they  do  not  come  in 
contact  with  the  skin  at  any  point.  Sinusoidal  and  the  secondary  faradic 
are  alternating  currents  and  there  can  therefore  be  no  distinction  as  to 
polarity. 

Effects.  The  positive  pole  is  a  vasoconstrictor,  the  negative  pole  a  vaso- 
dilator. For  this  reason  the  positive  pole  decreases  congestion,  the  nega- 
tive pole  increases  it.  The  positive  pole  has  a  sedative  effect,  the  negative 
pole  a  stimulant  or  irritant  effect.  These  are  the  reasons  for  placing  the 
positive  pole  at  the  head  and  the  negative  pole  at  the  feet  of  the  patient. 
As  a  neutral  temperature  is  used  the  total  effect  is  decidedly  sedative.  All 
forms  of  the  electric  tub  bath  are  disagreeable  to  some  persons.  These 
idiosyncrasies  should  not  be  ignored. 

The  temperature  and  duration  of  the  bath  and  the  strength  of  the  current 
should  be  specified  on  the  prescription.  The  bath  should  last  from  ten  to 
fifteen  minutes  and  from  twenty  to  thirty-five  milliamperes  be  used.  The 
amperage  should  not  be  high  enough  to  produce  an  unpleasant  sensation. 
If  there  are  saline  substances  dissolved  in  the  bath,  the  amperage  will  run 
much  higher  before  the  same  effects  are  produced  as  with  ordinary  water. 
With  thin  subjects  a  comparatively  low  amperage  must  be  used;  with  sub- 
jects in  good  flesh  or  over- weight  a  stronger  current  may  be  employed. 

MEDICATED  BATHS 

A  tub  bath  may  be  altered  by  the  addition  of  various  medicaments. 
Such  baths  are  not  of  great  practical  importance  except  in  a  very  limited 
number  of  skin  diseases. 

1.  Saline  Bath— Sal.  B.    Add  from  three  to  five  pounds  of  common  salt  to 
the  tub  of  water  at  90°  to  94°  F.  Time — ten  to  twenty  minutes.     The  addi- 
tion of  salt  adds  to  the  tonic  effect  through  stimulation  of  the  peripheral  cir- 
culation so  that  the  water  may  be  a  few  degrees  cooler  than  an  ordinary 
neutral  bath.     The  effect  is  similar  to  a  bath  in  sea  water. 

2.  Alkaline  Bath — Alk.  B.     Add  one-half  to  one  pound  of  bicarbonate  of 
soda  to  the  tub  of  water  at  a  neutral  temperature.     One-fourth  pound  of 
carbonate  of  soda  may  be  used.     Time— ten  to  twenty  minutes.     Effects- 
relieves  cutaneous  irritation,  itching,  etc.     Useful  in  certain  skin  diseases,  as 
eczema. 

NAUHEIM  BATH 

The  effervescent  or  artificial  Nauheim  bath  is  one  in  which  the  water  is 
charged  with  saline  substances  and  carbon  dioxide  gas.  Many  different 
formula  are  used  to  prepare  such  a  bath.  To  produce  the  carbon  dioxide 
gas  in  the  bath,  it  is  necessary  that  an  acid  come  in  contact  with  an  alka- 
line carbonate,  setting  free  the  carbon  dioxide;  or  salines  may  be  dissolved 
in  the  water  and  the  carbon  dioxide  added  from  a  generator.  Various  pro- 
prietary mixtures  prepared  in  cakes  are  offered  for  use. 

In  using  these,  dissolve  the  sodium  chloride  and  sodium  bicarbonate  in 
forty  or  fifty  gallons  of  water.  The  bottom  of  the  tub  is  then  covered  with 
rubber  sheeting.  On  this  rubber  sheeting  place  the  acid  cakes.  In  about 


270  TECHNIQUE  OF  HYDROTHERAPY 

three  minutes,  when  effervescence  is  well  under  way,  the  patient  should  lie 
down  in  the  bath. 
A  very  complete  and  satisfactory  formularis  the  following: — 

Sodium  carbonate  (sal  soda) 1J  Ib 

Sodium  bicarbonate  (baking  soda) \   " 

Calcium  chloride 3     " 

Sodium  chloride  (common  salt) 2     " 

Sodium  bisulphate 1     " 

After  mixing  the  first  four,  dissolve  in  a  few  inches  of  warm  water  in  the 
bottom  of  the  bath  tub.  When  thoroughly,  dissolved,  fill  the  tub  with  water 
at  the  desired  temperature.  The  sodium  bisulphate  which  is  the  acid  part  of 
the  formula,  should  be  granular  or  finely  pounded  and  dissolved  separately  in 
a  wooden  or  paper  pail  containing  hot  water.  As  it  may  require  some  time 
for  this  to  dissolve,  it  should  be  prepared  before  the  bath  is  to  be  given. 
When  thoroughly  dissolved  pour  into  the  tub  and  quickly  mix  with  the  rest 
of  the  water.  The  bath  is  now  ready  for  use.  The  amounts  of  the  saline 
ingredients  may  be  gradually  increased  for  the  succeeding  baths  of  a  course. 

Three-fourths  of  a  pound  of  commercial  hydrochloric  acid  may  be  used  in 
place  of  the  sodium  bisulphate.  This  should  be  mixed  with  two  or  three 
times  its  volume  of  water,  and  after  the  salts  are  all  dissolved  and  the  tub 
filled  with  water  at  the  desired  temperature,  the  bottle  containing  the  acid 
should  be  opened  under  water".  It  may  be  moved  about  to  hasten  the  diffu- 
sion of  the  acid  into  the  water  of  the  bath. 

The  following  is  a  simpler  and  less  expensive  formula: — 

Sodium  chloride 3  to  8  Ib 

Sodium  bicarbonate f  to  1£  " 

Sodium  bisulphate  (commercial) 1     " 

The  temperature  of  the  bath  should  range  from  85°  to  92°  F.  The  lower 
temperatures  should  be  used  for  the  later  baths  of  a  series.  The  duration 
of  the  bath  should  at  first  be  from  five  to  eight  minutes.  The  time  may 
then  be  gradually  extended  to  fifteen  or  even  twenty  minutes.  A  cold  com- 
press should  be  applied  to  the  head  and  an  ice  bag  to  the  heart.  The  patient 
should  not  be  rubbed  during  the  bath.  About  three  baths  a  week  may  be 
taken  for  three  or  four  weeks.  Not  over  twenty  baths  should  constitute  a 
course. 

Effects  and  Therapeutic  Use.  The  effects  of  the  bath  are  due  to  the 
cutaneous  stimulation  of  the  vasomotors  produced  by  the  carbon  dioxide 
and  salines  dissolved  in  the  water.  The  peripheral  heart  is  stimulated  and 
the  cutaneous  circulation  greatly  hastened.  The  heart  beats  slower  and 
with  greater  ease.  In  normal  individuals  there  may  be  a  fall  of  ten  or  fif- 
teen beats  in  the  pulse  rate  following  a  single  bath,  while  in  case  of  a  very 
rapid  pulse  the  decrease  may  reach  as  high  as  twenty-five  to  forty  beats  per 
minute.  Examination  of  the  heart  after  the  bath  in  cases  of  a  valvular 
lesion  or  cardiac  dilatation,  show  a  stronger,  steadier  beat;  the  rhythm 
becomes  regular,  the  sounds  clearer,  and  certain  murmurs  may  disappear 
entirely.  The  pulse  becomes  full  and  blood  pressure  rises  20  or  30  mm. 
The  area  of  dullness  of  an  enlarged,  dilated  heart  is  often  lessened  one-half 
inch  or  more  all  around  its  border.  Both  the  systole  and  the  diastole  are 
lengthened. 


BATHS  271 

The  Nauheim  bath  also  stimulates  metabolism  and  hastens  the  elimination 
of  gouty  toxins.  It  exerts  a  beneficial  effect  upon  nutrition  and  is  therefore 
of  much  use  in  diseases  of  metabolism. 

If  a  course  of  baths  is  continued  too  long,  over-stimulation  results,  pas- 
sive dilatation  of  the  blood  vessels  occurs  and  the  heart  beats  with  less 
force.  The  rhythm  is  disturbed  and  there  will  be  palpitation.  This  may  be 
guarded  against  by  keeping  the  duration  of  the  bath  well  within  fifteen  min- 
utes, stopping  short  of  the  maximum  number  of  baths  that  may  be  used  in 
one  course,  and  by  using  the  ice  bag  over  the  heart  during  the  treatment. 

The  heart  should  be  carefully  examined  by  palpation,  percussion  and  aus- 
cultation both  before  and  after  the  bath.  This  will  enable  the  physician  to 
prescribe  much  more  intelligently  and  obviate  any  difficulty  that  may  arise. 

The  Nauheim  bath  is  useful  in  valvular  insufficiency  and  stenosis,  cardiac 
dilatation,  hyperthyroidism  and  in  cardiac  neuroses.  It  is  also  useful  in 
Bright's  disease,  chronic  articular  rheumatism,  gout  and  obesity.  The  bath 
is  countra-indicated  in  extreme  arterio-sclerosis,  in  aneurism  and  in  angina 
pectoris.  It  should  not  be  used  in  acute  inflammatory  diseases  nor  in  the 
acute  stage  of  endocarditis.  Some  highly  recommend  its  use  in  locomotor 
ataxia. 

III.    MISCELLANEOUS 

RUSSIAN  BATH 

The  Russian  bath  consists  in  the  immersion  of  the  body  in  hot  vapor.  The 
steam,  as  it  is  turned  into  the  Russian  room,  partially  condenses  and  hangs 
suspended  as  a  thick  fog.  For  every  gram  of  steam  that  thus  condenses, 
537  calories  of  heat  are  liberated.  This  fact  accounts  for  the  intense  heat- 
ing effect  obtained  by  the  use  of  this  form  of  hot  treatment. 

For  the  Russian  bath  provide  a  steam  tight  room  with  a  marble  slab.  A 
sliding  window  should  be  so  arranged  at  the  end  of  the  slab  that  the  patient's 
head  may  be  outside  of  the  steam  room.  The  steam  should  enter  below  the 
slab  so  as  not  to  strike  the  patient  directly,  and  be  controlled  by  a  valve 
near  the  sliding  window  so  that  the  attendant  may  regulate  the  amount  of 
steam  and  keep  the  head  cool  at  the  same  time  by  frequently  changed  cold 
compresses  to  the  head  and  neck. 

Procedure.  Move  the  bowels  by  an  enema  and  give  a  preliminary  hot 
foot  bath.  Have  the  patient  drink  water  before,  and  frequently  during, 
the  bath.  This  is  necessary  in  order  to  provide  for  the  profuse  perspira- 
tion which  the  treatment  should  induce.  See  that  the  slab  is  warm;  if  not, 
pour  over  it  several  pails  of  hot  water.  Warm  the  room  to  about  100°  F., 
and  cover  the  slab  with  a  folded  sheet. 

The  patient  is  now  assisted  onto  the  table  and  lies  on  the  back  with  the 
head  on  an  air  pillow  just  without  the  opening.  The  window  is  lowered  and 
a  towel  wrung  from  ice  water  is  placed  about  the  neck,  or  hung  across  the 
lower  end  of  the  window  and  tucked  around  the  neck.  Another  cold  com- 
press is  applied  to  the  head  and  covers  the  temporal  arteries.  A  third  cold 
compress  should  be  applied  to  the  precordia.  In  some  cases  it  will  be  neces- 
sary to  use  an  ice  bag  over  the  heart. 

Next  turn  on  the  steam,  gradually  raising  the  temperature  of  the  room 
to  115°  or  120°  F.  A  small  amount  of  steam  should  be  constantly  escaping 


272  TECHNIQUE  OF  HYDROTHERAPY 

to  maintain  the  temperature.  Change  the  compresses  to  the  head  and  neck 
frequently.  The  patient  should  be  closely  watched  during  the  entire  time 
of  the  treatment  The  bath  should  last  from  ten  to  thirty  minutes.  Just 
before  the  patient  rises  from  the  slab,  renew  the  ice  compress  to  the  head. 
Finish  the  treatment  with  a  graduated  or  alternate  spray  or  shower,  or 
better  still,  a  shampoo  and  graduated  shower.  The  spray  or  shower  should 
be  in  the  Russian  room  or  only  a  few  steps  from  it. 

Effects.  The  effects  of  vigorous  sweating  measures  have  been  considered 
elsewhere.  The  "washing  out"  effect  is,  perhaps,  the  greatest,  and  the 
thoroughness  of  this  depends  very  largely  upon  the  water  taken  before  and 
during  the  treatment.  Sweating  measures  greatly  increase  catabolism, 
especially  of  carbohydrates  and  fats.  The  products  of  nitrogenous  metab- 
olism show  more  complete  oxidation. 

The  Russian  bath  is  of  great  service  in  obesity,  chronic  rheumatism  with 
obesity,  gout,  Bright's  disease,  autointoxications,  chronic  alcoholism,  and 
in  arterio-sclerosis  unless  extreme.  It  is  countra-indicated  in  diabetes,  val- 
vular heart  disease,  all  diseases  associated  with  emaciation  and  in  extreme 
arterio-sclerosis. 

CABINET  VAPOR  BATH 

The  principle  involved  in  the  cabinet  vapor  bath  is  the  same  as  that  of 
the  Russian  bath.  Various  water-proof  cabinets  are  offered  for  sale.  They 
are  useful  in  a  home  where  more  elaborate  facilities  can  not  be  provided. 
An  alcohol  stove  heats  water  in  a  basin  under  or  near  the  stool  provided  for 
the  patient.  This  is  continued  until  the  cabinet  is  full  of  vapor,  when  it  is 
ready  to  enter.  The  patient  sits  on  the  stool  with  the  head  outside  of  the 
cabinet.  The  duration  of  the  treatment  should  depend  upon  the  rapidity  of 
vaporization  and  upon  the  effect  desired.  The  preliminaries,  procedure  and 
precautions  to  be  taken  are  the  same  as  in  the  Russian  bath.  Conclude  the 
treatment  with  a  shampoo,  cold  towel  rub,  graduated  shower  or  other  cold 
application. 

TURKISH  BATH 

The  Turkish  bath  consists  in  the  immersion  of  the  body  in  hot  air.  The 
Russian  room  may  be  used  for  this  purpose  and  conveniently  heated  by 
steam  coils.  The  patient  is  treated  in  the  same  manner  as  in  the  Russian 
bath.  The  head  and  neck  should  be  kept  cool  by  cold  compresses  and,  if 
necessary,  an  ice  bag  applied  over  the  heart.  The  temperature  of  the  room 
should  be  gradually  raised  from  120°  to  about  170°  F.  The  bath  may  last 
from  fifteen  to  forty-five  minutes.  Perspiration  is  often  somewhat  delayed, 
in  which  case  brisk  friction  to  the  skin  may  hasten  its  appearance.  If  per- 
spiration is  much  delayed,  the  patient  is  likely  to  behave  badly  in  the  hot  air 
bath  and  for  this  reason  should  be  closely  watched  until  free  perspiration  is 
established.  Owing  to  the  difficulty  with  which  some  patients  react  to  dry 
hot  air,  the  applicability  of  the  Turkish  bath  is  somewhat  more  limited  than 
that  of  the  Russian  bath. 

SUPERHEATED  AIR  BATH 

In  the  superheated  air  bath  the  temperature  reaches  250°  to  350°  F. 
Special  metal  cabinets  for  the  entire  body  or  various  parts  may  be  pur- 


BATHS  273 

chased.  The  body  or  part  to  be  treated  should  be  thoroughly  wrapped  in 
Turkish  toweling  and  should  not  rest  on  any  part  of  the  cabinet  likely  to 
become  hot  enough  to  burn.  By  means  of  a  gasoline  or  other  burner,  the 
temperature  of  the  air  in  the  cabinet  is  gradually  raised  to  250°  or  350°  F. 
These  burners  are  placed  just  below  the  cabinet;  over  them  are  fitted 
inverted  funnels  with  a  short,  wide  stem  leading  directly  into  the  cabinet. 
The  entering  hot  air  should  be  spread  by  means  of  an  asbestos  shield  so  that 
it  will  not  directly  strike  the  skin  surface.  The  patient's  pulse  and  general 
condition  must  be  watched  very  closely  in  giving  a  full  hot  air  bath.  An 
ice  bag  should  be  kept  on  the  heart  and  ice  compresses  on  the  head  and 
neck.  These  precautions  are  not  so  necessary  where  only  a  single  part  such 
as  the  knee  or  foot  and  ankle  are  being  treated.  The  treatment  may  be 
concluded  by  an  alcohol  or  witchhazel  rub.  Great  care  must  be  exercised 
that  the  patient  does  not  take  cold  afterward. 

The  Turkish  toweling  with  which  the  body  or  limb  is  wrapped  quickly 
absorbs  the  perspiration  thus  preventing  its  collecting  on  the  skin  in  drops. 
Should  it  collect  in  drops,  burning  is  more  likely  to  result. 

Effects.  The  superheated  air  bath  is  a  much  more  vigorous  measure 
than  the  Turkish  bath.  It  is  of  special  advantage  in  articular  rheumatism, 
whether  occurring  in  acute  rheumatic  fever,  chronic  gouty  rheumatism  or  in 
specific  arthritis.  Where  one  or  two  joints  are  being  treated,  the  applica- 
tion should  continue  from  twenty  minutes  to  an  hour  after  the  temperature 
has  reached  300°  to  350°  F.  When  the  part  is  taken  out  a  momentary  dash 
of  cold  water  may  be  given  or  the  part  cleansed  from  perspiration  and  a 
heating  compress  applied.  In  gonorrheal  rheumatism  this  treatment  may 
be  followed  by,  or  alternate  with,  the  prolonged  ice  pack,  i.  e.,  prolonged 
to  about  one  hour's  duration. 

ELECTRIC  LIGHT  BATH 
(E.  L.  B.) 

In  giving  the  electric  light  bath,  special  upright  or  reclining  cabinets 
fitted  with  mirrors  and  incandescent  lights  are  used. 

The  feet  should  be  warmed  beforehand,  or  with  the  upright  cabinet  a  hot 
foot  bath  should  be  used.  Cover  the  stool  with  a  folded  Turkish  towel. 
Turn  on  the  desired  number  of  lights;  when  the  cabinet  is  warmed,  have  the 
patient  enter.  Then  close  the  cabinet  and  apply  a  cold  wet  towel  to  the 
head  and  neck.  Renew  this  frequently.  If  there  is  a  tendency  to  f aintness 
or  rapid  pulse,  use  an  ice  bag  to  the  heart  as  well.  If  a  horizontal  cabinet 
is  used,  cover  the  table  with  a  folded  sheet.  Warm  the  cabinet  and  place 
a  rubber  pillow  for  the  patient's  head.  The  patient  then  lies  down  and  is 
rolled  into  the  cabinet,  or  the  top  is  lowered  according  to  the  style  of  cabi- 
net used.  The  patient's  head  should  be  kept  cool  by  cold  compresses. 
There  is  less  tendency  to  fainting  with  the  horizontal  than  with  the  upright 
cabinet. 

The  patient  must  be  watched  very  carefully  and  constantly  in  order  to 
guard  against  fainting.  On  leaving  the  cabinet,  a  blanket  or  sheet  should 
be  thrown  about  the  patient  if  it  is  necessary  to  go  more  than  a  few  steps 
for  the  next  part  of  the  treatment.  Finish  with  a  spray  or  shampoo  and 
spray.  Where  only  general  tonic  effects  are  desired,  the  electric  light  bath 


274  TECHNIQUE  OF  HYDROTHERAPY 

should  last  from  three  to  five  or  six  minutes;  for  profuse  sweating  and  elimi- 
native  effects,  continue  it  from  ten  to  eighteen  or  twenty  minutes. 

Effects.  The  incandescent  electric  light  is  not  so  much  a  generator  of 
actinic  rays  as  of  heat  rays.  It  is  said  that  only  five  to  eight  per  cent  of 
the  radiant  energy  of  the  incandescent  light  consists  of  actinic  rays,  while 
ninety-two  per  cent  is  in  the  form  of  heat  rays.  For  this  reason  the  use  of 
blue  globes  adds  nothing  to  the  chief  effect  of  the  bath,  but  rather  detracts 
from  it,  since  the  volume  of  the  heat  rays  is  lessened.  The  incandescent 
electric  light  bath  is  not  a  phototherapeutic  but  a  thermotherapeutic  appliance. 

The  air  of  the  cabinet  is  not  warmed  to  the  same  extent  as  the  skin  of  the 
patient,  since  the  heat  is  aot  in  the  form  of  radiant  energy.  In  this  parti- 
cular the  electric  light  bath  differs  essentially  from  the  Russian  or  Turkish 
bath  and  from  the  effect  produced  by  hot  applications  applied  directly  to  the 
skin.  This  means  that  the  heat  of  the  electric  light  is  not  communicated  to 
the  body  by  direct  conduction  or  by  convection,  but  by  the  absorption  of  the 
rays  of  radiant  energy  as  they  are  retarded  and  stopped  by  the  skin  and 
subcutaneous  tissues. 

On  the  other  hand,  for  strong  derivative  effects,  the  electric  light  bath  is 
unsatisfactory.  For  derivative  purposes  the  heat  must  be  brought  in  actual 
contact  with  the  skin  by  applying  the  heated  substance  directly  to  the  skin. 
For  this  reason,  stronger  derivative  effects  are  secured  by  partial  or  full  hot 
baths  and  hot  packs. 

The  uses  of  the  electric  light  bath  are  numerous  and  considerable  space 
would  be  required  merely  to  enumerate  them.  However,  it  is  of  special 
advantage  in  Bright's  disease,  arteriosclerosis,  lead  poisoning  and  other 
toxemias,  obesity,  gout,  acute  and  chronic  rheumatism,  neurasthenia,  dia- 
betes, skin  diseases  and  also  for  general  tonic  and  sudorific  effects. 


SHAMPOOS 

SWEDISH  SHAMPOO 

(Ssh.) 

For  giving  the  Swedish  or  slab  shampoo,  provide  a  pail  of  water  at  103° 
to  105°  F.  on  a  stool  of  convenient  height  near  the  head  of  the  slab,  also 
a  shampoo  brush  and  a  half  bar  of  soap.  If  the  slab  is  not  kept  warm  by 
being  in  a  warm  room,  pour  over  it  two  or  three  pails  of  hot  water.  Cover 
the  slab  with  a  doubled  sheet,  and  assist  the  patient  onto  the  slab,  placing 
the  head  on  an  air  pillow.  Quickly  lather  an  arm  by  dipping  the  brush  and 
soap  in  the  pail  of  hot  water  and  rubbing  together  over  the  part.  With 
brisk  short  movements  go  over  the  part  thoroughly,  using  as  much  friction 
as  is  comfortably  borne.  Do  the  same  with  the  chest,  abdomen  and  legs. 

Next  assist  the  patient  to  turn  over  on  the  slab  by  putting  one  arm  under 
the  neck  and  grasping  the  opposite  shoulder,  and  the  other  arm  under  the 
near  leg  and  grasping  the  opposite  knee.  Treat  the  back,  hips  and  the  backs 
of  the  legs  in  the  same  manner  as  the  front  of  the  body.  Pour  the  remain- 
ing water  in  the  pail  over  the  patient  to  rinse  off  the  soap  suds.  Follow 
the  shampoo  by  a  warm  and  cold  shower,  spray  or  pail  pour. 


SHAMPOOS  275 

TUB  SHAMPOO 

(Tub  Sh.) 

Fill  a  bath  tub  with  water  at  98°  F.  The  patient  may  sit  on  a  wooden 
stool  in  the  tub  or,  if  likely  to  chill,  he  should  lie  down  in  the  tub  with  the 
water  deep  enough  to  cover  the  chest.  If  given  with  the  patient  sitting  on 
a  stool,  begin  with  the  arms,  back,  chest  and  abdomen,  then  the  legs.  If 
given  with  the  patient  immersed,  raise  one  part  at  a  time  above  the  water 
and  proceed  as  usual,  having  the  patient  sit  for  the  back  and  chest.  Finish 
by  complete  immersion  in  the  tub  followed  by  a  cold  pail  pour  or  shower. 

TURKISH  SHAMPOO 

(Tur.  Sh.) 

The  Turkish  shampoo  is  given  after  sweating  baths  such  as  the  Turkish, 
Russian  or  electric  light  bath.  The  shampoo  proper  is  preceded  by  manipula- 
tions and  heavy  friction  to  loosen  the  outer  epidermis  (so-called  dead  skin) . 
It  is  the  most  thorough  cleansing  measure  used. 

a.  Articles  Necessary.  Two  pails  of  water  at  90°  F.,  one  at  100°  to  105C 
F. ,  loofah  or  shampoo  brush,  soap,  two  Turkish  toweling  mitts,  two  sheets 
and  towels.  In  treating  women,  the  hair  should  be  protected  by  a  rubber 
cap.  • 

6.  Procedure.  If  the  sweating  bath  has  not  been  taken  in  the  shampoo 
room,  it  must  be  well  heated  and  the  slab  warmed  by  pails  of  hot  water 
poured  over  it.  Cover  with  a  doubled  sheet  and  assist  the  patient  onto  the 
slab.  Place  an  air  pillow  under  the  head. 

Manual  Rubbing.  Wet  the  face  with  water  at  90°  F.  With  the  hands, 
dash  water  over  every  part  separately,  using  long  strokes  and  quickly 
covering  the  body.  Beginning  with  the  neck,  about  the  ears,  hair,  forehead, 
over  the  nose  and  chin,  rub  until  the  dead  skin  is  thoroughly  loosened.  Wash 
off  the  loosened  epidermis,  dipping  the  hands  frequently.  For  the  chest  and 
abdomen,  after  applying  the  water,  use  transverse  wringing  and  re-enforced 
rubbing,  covering  each  part  several  times.  Then  wash  off  with  water. 
For  the  arms  use  spiral  friction  and  wringing.  For  the  legs,  the  same; 
with  the  thumbs,  rub  well  about  the  ankles,  soles  of  feet,  knees,  etc. 
Turn  the  patient  and  proceed  with  the  back  in  the  same  manner  as  with 
the  chest,  also  the  thighs  and  legs.  Wash  off  the  entire  surface  with  water. 

Friction  Mitt.  Dip  the  mitt  in  the  second  pail  of  water  at  90°  F.,  and 
beginning  with  the  back  and  backs  of  thighs  and  legs  go  over  each  part 
twice,  rubbing  all  thoroughly.  Then  turn  the  patient  and  treat  the  chest, 
abdomen,  arms  and  legs  in  the  same  manner.  Wash  off  with  the  rest  of  the 
pail  of  water  at  90°  F. 

Shampoo.  Treat  each  part  as  in  the  Swedish  shampoo  using  hands,  a 
loofah,  or  bath  brush  and  the  pail  of  water  at  105°  F. 

Finish  with  prolonged  tepid  or  cool  shower  or  spray,  and  at  the  close  a 
short  cold  spray.  Dry  thoroughly  with  sheets  and  towels.  The  patient 
should  be  careful  not  to  take  cold  afterward. 


276  TECHNIQUE  OF  HYDROTHERAPY 

PACKS 

Packs  are  procedures  in  which  a  considerable  portion  of  the  body  is 
enveloped  in  wet  sheets  or  blankets  for  therapeutic  purposes. 

I.    HOT  BLANKET  PACKS 

The  hot  blanket  pack  is  a  procedure  in  which  hot  blankets  are  used  to 
communicate  heat  to  the  body. 

FULL  HOT  BLANKET  PACK 
(II.    B.    P.) 

a.  Articles  Necessary .    Two  double  blankets  or  one  single  and  one  double 
blanket;  one  hot  water  bottle  and  three  spine  bags  half  filled  with  hot  water  at 
160°  F.,  a  bowl  or  pail  of  ice  water  with  compresses  for  the  head,  neck  and 
heart;    two  Turkish  towels;  a  tumbler,  a  drinking  tube  and  pitcher  of  hot 
water  for  drinking. 

b.  Preliminaries.    Move  the  bowels  by  enema,  give  a  hot  foot  bath,  and 
have  the  patient  drink  hot  water. 

c.  Procedure.    Spread  a  double  blanket  on  the  treatment  table  or  bed. 
Adjust  a  cold  compress  to  the  patient's  head  while  his  feet  are  still  in  the 
hot  foot  bath.     Fold  the  single  blanket  or  another  double  blanket  (the  latter 
holds  the  heat  longer)  lengthwise  in  convenient  width  for  passing  through 
a  wringer  or  wringing  by  hand.     Wring  from  boiling  water,  quickly  unfold 
and  spread  out  over  the  dry  blanket  on  the  table. 

Assist  the  patient  to  lie  on  the  hot  blanket,  or  with  a  bed  patient  lift  onto 
the  blanket.  As  quickly  as  possible  or  as  rapidly  as  can  be  borne,  envelope 
the  entire  body  except  the  head  in  the  hot  blanket.  Place  one  spine  bag 
between  the  legs  with  one  thickness  of  dry  blanket  between  it  and  the 
moist  blanket,  and  the  hot  water  bottle  at  the  feet.  The  other  spine  bags 
should  be  placed  along  the  sides  of  the  trunk  in  the  same  way  as  the  one  to 
the  legs.  Tuck  both  wet  and  dry  blankets  in  well,  especially  at  the  feet 
and  about  the  shoulders  and  neck,  so  as  to  exclude  the  air.  See  that  the 
wet  blanket  comes  in  contact  with  the  body  over  its  entire  surface,  so  that 
no  air  spaces  will  be  left. 

Place  cold  compresses  about  the  head  and  neck  and  protect  the  chin  from 
the  hot  blanket  by  a  soft  dry  towel.  Renew  the  compresses  before  they  are 
warmed  to  any  extent. 

For  general  sweating  effects  a  dry  blanket  may  be  placed  between  the 
patient  and  the  wet  blanket,  but  for  strong  derivative  effects  the  wet 
blanket  should  come  into  immediate  contact  with  the  skin. 

The  patient  should  perspire  in  a  short  time.  If  perspiration  does  not 
begin  in  about  ten  minutes,  give  hot  water  to  drink  or  a  hot  foot  bath,  or 
both.  In  giving  the  hot  foot  bath  the  blankets  should  fall  loosely  about  the 
tub  so  as  to  prevent  the  circulation  of  air. 

Continue  the  pack  for  twenty  to  thirty  minutes,  i.  e.,  until  it  ceases  to 
have  a  heating  effect.  For  tonic  effects,  five  to  ten  minutes.  Take  the  patient 
out  by  a  cold  mitten  friction  or  a  cold  towel  rub,  removing  the  blanket  from 
one  part  at  a  time  and  covering  with  a  dry  blanket  or  bedding  immediately 


PACKS  277 

after.  It  is  usually  most  convenient  to  begin  with  the  arms,  then  the  chest 
and  abdomen,  legs  last,  giving  the  cold  friction  to  the  back  after  the  wet 
blanket  has  been  entirely  removed. 

d.  Precautions.     Too  much  water  left  in  the  pack  makes  it  feel  very  hot 
at    first  but  it  cools  more  rapidly  than  when  wrung  nearly  dry.     For  this 
reason  the  pack  should  be  wrung  as  dry  as  possible. 

If  the  hot  water  bags  are  too  near  the  patient  (not  sufficiently  covered) 
there  is  danger  of  burns  resulting.  If  complaint  is  made,  they  should  at 
once  be  covered  more  thoroughly. 

In  some  cases  it  is  necessary  to  use  a  cold  compress  or  an  ice  bag  to  the 
heart. 

General  free  perspiration  should  be  induced  by  the  pack.  Long  continued 
heat  without  perspiration  results  in  harm. 

In  giving  packs  in  case  of  paralyzed  sensation,  unconsciousness,  under  or 
soon  after  anesthesia,  in  diabetics,  dropsy  and  the  insane,  it  is  safer  if  a 
thickness  of  dry  blanket  intervene  between  the  patient  and  the  wet  blanket. 
Hot  water  bottles  should  be  more  thoroughly  covered  and  the  water  used  in 
them  should  be  at  a  lower  temperature  than  ordinary. 

e.  Effects.     The  hot  blanket  pack   is  a  vigorous    sweating  measure.     It 
also  produces  decided  derivation.     Any  sweating  treatment  decreases  inter- 
nal congestion,  but  this  action  is  mach  more  marked  when  the  wet  blanket 
is  placed  next  to  the  skin.     Where  the  congestion  is  not  localized  in  some 
particular  part,  but  consists  of  a  general    internal    congestion,    a    general 
sweating  treatment  is  usually  sufficient  for  its  relief.     This  is  the  case  in 
the  first    stage    of   many    fevers,    especially    the    exanthemata,    in    colds, 
la  grippe,  etc. 

In  uremia,  eclampsia  and  acute  Bright's  disease,  both  sudorific  and  strong 
derivative  effects  should  be  secured.  In  other  forms  of  renal  congestion 
this  is  also  necessary.-  In  kidney  insufficiency  the  skin  excretes  much  larger 
quantities  of  poison  than  in  health.  Free  or  profuse  perspiration  greatly 
aids  in  this  vicarious  function.  This  effect  is  not,  however,  the  only  one 
nor  the  most  important  effect  of  sweating  measures.  The  congestion  of  the 
skin  secured  by  a  hot  pack  reduces  the  congestion  and  high  blood  pressure 
in  the  kidney  so  that  it  soon  begins  to  functionate  when  these  causes  are 
removed.  The  hoi  blanket  pack  is  also  useful  in  pneumonia  and  sometimes 
in  typhoid  fever.  It  is  almost  indispensible  in  the  treatment  of  renal  colic 
and  gallstone  colic.  In  these  conditions  the  pain  is  decreased  immediately 
the  pack  is  applied;  in  some  cases  it  entirely  obviates  the  necessity  formor- 
phin,  while  in  others  the  dose  may  be  cut  to  one-third  or  one-fourth  the 
amount  that  would  otherwise  be  required. 

DRY  BLANKET  PACK 
(1).  B.  P.) 

Sweating  may  be  produced  by  enveloping  the  body  in  a  dry  woolen 
blanket  and  using  hot  water  bottles  in  the  same  way  as  with  a  wet  pack.  The 
same  preliminaries  should  be  observed,  especially  the  giving  of  the  hot  foot 
bath  before.  It  is  quite  essential  that  the  patient  take  a  considerable  quan- 
tity of  a  hot  drink  during  the  treatment.  Hot  lemonade  is  ideal  as  it  favors 
both  diaphoresis  and  diuresis.  The  sweating  may  be  as  profuse  as  with  the 


278  TECHNIQUE  OF  HYDROTHERAPY 

wet  pack  but  the  derivation  is  less  efficient.  Since  no  wet  blanket  is  used, 
the  patient  may  be  first  wrapped  in  a  dry  sheet  and  then  in  the  dry  blanket. 
The  perspiration  will  be  absorbed  by  the  sheet  and  so,  in  a  short  time,  the 
effect  will  somewhat  approach  that  of  the  sweating  wet  sheet  pack. 

HOT  TRUNK  PACK 
(H.  Tr.  Pk.) 

The  method  of  applying  the  hot  trunk  pack  is  the  same  afe  with  the  full 
blanket  pack.  The  wet  blanket  should  include  the  pelvis  but  exclude  the 
arms,  reaching  up  to  the  axilla.  The  outside  dry  blanket  should  include 
the  whole  body  but  be  used  only  for  protection;  it  should  not  be  wrapped 
tightly  about  the  patient.  It  is  usually  best  to  apply  a  large  dry  fomenta- 
tion cloth  between  the  patient  and  the  wet  blanket.  Place  a  hot  water 
bottle  over  the  abdomen  between  the  folds  of  the  dry  blanket,  and  spine 
bags  on  either  side  of  the  trunk.  A  hot  foot  bath  should  begin  before  and 
continue  during  the  pack.  Time — twenty  to  thirty  minutes.  If  given  for 
the  relief  of  the  pain  of  any  form  of  colic,  omit  the  cold  friction  at  the  close. 

The  hot  trunk  pack  has  the  same  general  effect  as  the  hot  blanket  pack. 
Since  it  covers  less  surface  the  derivative  effects  are  less.  It  is  especially 
useful  in  digestive  disturbances  and  in  relieving  the  pain  of  renal  and  biliary 
colic,  also  in  intestinal  colic. 

ALTERNATE  HOT  AND  COLD  TRUNK  PACK 
(Alt.  H.  &  C.  Tr.  Pk.) 

The  alternate  hot  and  cold  trunk  pack  consists  of  a  hot  trunk  pack  given 
as  directed  above  and  followed  by  a  wet  sheet  trunk  pack.  Only  this  one 
change  from  heat  to  cold  is  made.  The  wet  sheet  is  wrung  from  water  at 
about  60°  F.  and  applied  to  the  trunk  after  removing  the  wet  flannel  blanket. 
The  method  is  described  under  the  heading  of  wet  sheet  packs. 

The  hot  blanket  should  be  removed  while  it  is  still  hot  and  the  wet  sheet 
applied  at  once  in  much  the  same  manner  as  for  the  revulsive  compress. 
The  wet  sheet  trunk  pack  should  remain  in  place  until  the  heating  stage  is 
reached  when  it  may  be  removed  and  a  cold  mitten  friction  or  alternate  hot 
and  cold  spray  douche  given  to  the  parts  covered  by  the  pack,  finishing  with 
the  same  to  the  feet.  If  desired,  the  wet  sheet  trunk  pack  may  be  made  a 
hot  and  heating  trunk  pack  by  inserting  a  hot  water  coil  or  a  hot  water 
bottle  over  the  stomach. 

The  alternate  hot  and  cold  trunk  pack  is  used  for  tonic  purposes  also  in 
chronic  congestions  of  the  liver  and  the  other  digestive  organs. 

HOT  PELVIC  PACK 
(H.  Pelv.  Pk.) 

The  hot  pelvic  pack  is  applied  in  the  same  manner  as  the  hot  trunk  pack. 
It  should  come  well  above  the  crests  of  the  ilia  and  include  nearly  half  of  the 
thighs.  It  is  useful  in  the  relief  of  pelvic  pain  from  dysmenorrhoea,  cystitis, 
proctitis,  etc.  Its  effects  do  not  greatly  differ  from  those  of  the  hot  sitz 
bath  or  large,  very  hot  fomentations  to  the  pelvis,  both  of  which  treatments 
are  much  easier  to  apply. 


PACKS  279 

ALTERNATE  HOT  AND  COLD  PELVIC  PACK 
Alt.  H.  &  C.  Pelv.  Pk. 

This  treatment  is  applied  in  the  same  way  as  the  alternate  hot  and  cold 
trunk  pack.  The  cold  pack  should  be  prolonged  to  the  heating  stage.  The 
effects  are  somewhat  similar  to  those  of  the  revulsive  sitz  and  hot  half  bath. 
It  is  useful  in  chronic  congestions  and  chronic  inflammations  of  the  pelvic 
organs,  such  as  chronic  metritis  and  endometritis  with  much  thickening, 
also  in  subinvolution. 

HOT  HIP  AND  LEG  PACK 
(H.  Hp.  &  Lg.  Pk.) 

The  hip  and  leg  pack  should  include  the  feet,  legs,  thighs  and  pelvis,  reach- 
ing slightly  above  the  crests  of  the  ilia.  A  hot  water  bottle  should  be  placed 
at  the  feet  within  the  folds  of  the  dry  blanket  and  a  spine  bag  between  the 
legs.  Time — twenty  to  forty  minutes.  Taking  one  limb  out  at  a  time,  finish 
with  a  cold  mitten  friction  to  retain  the  blood  in  the  limbs,  thus  maintaining 
the  derivation  secured  by  the  hot  pack. 

Effects.  The  hot  hip  and  leg  pack  is  one  of  the  most  efficient  derivative 
measures  used  in  hydrotherapy.  It  is  indicated  in  a  large  number  of  condi- 
tions, and  is  especially  useful  in  depleting  acutely  inflamed  organs  when 
combined  with  the  use  of  an  ice  bag  over  the  congested  part.  (See  Hot 
Packs  with  Ice  Bags) 

HOT  LEG  PACK 

(H.  Lg.  Pk.) 

The  hot  leg  pack  should  include  the  feet,  legs,  knees  and  half  or  more  of  the 
thighs.  Hot  water  bottles  are  used  the  same  as  above.  Conclude  the  treat- 
ment in  the  same  way. 

The  leg  pack  is  somewhat  less  effective  than  the  hip  and  leg  pack.  It  is 
used  for  the  same  purposes,  and  is  convenient  where  it  is  undesirable  to 
move  the  pelvis  in  giving  treatment.  A  large  fomentation  may  be  used 
over  the  anterior  surface  and  sides  of  the  pelvis  at  the  same  time,  so  as  to 
cover  nearly  as  much  surface  as  the  hip  and  leg  pack. 


Hot  packs  combined  with  the  use  of  ice  bags,  or  the  ke  water  coil,  are 
the  most  powerful  and  efficient  derivative  measures  known  to  hydrotherapy. 
They  are  especially  useful  in  reducing  internal  congestions,  reducing  or 
aborting  local  inflammation  of  deep  parts  and  relieving  the  pain  incident  to 
the  inflammatory  process.  For  these  purposes  they  are  used  only  in  the 
acute  stage  of  the  inflammatory  process.  The  effects  have  been  fully  dis- 
cussed in  the  consideration  of  inflammation  and  antiphlogistic  effects,  q.  v. 

The  hot  pack  depletes  the  congested  part  by  drawing  the  blood  away  to 
establish  a  collateral  hyperemia  (pull  effect)  while  the  ice  bag  drives  the 
blood  away  by  reflexly  stimulating  prolonged  and  extreme  contraction  of  the 
deep  vessels  of  the  inflamed  part  (push  effect).  (PLATE  III)  The  cold 
mitten  friction  given  at  the  close  causes  retention  of  the  blood  in  the  skin 
by  changing  the  passive  hyperemia  to  an  active  arterial  hyperemia. 

These  treatments  are  sometimes  spoken  of  as  hot  and  cold  packs,  but  this 


280  TECHNIQUE  OF  HYDROTHERAPY 

designation    may  cause  confusion  with  the  alternate  hot  and  cold  pack  in 
which  a  cold  (heating)  wet  sheet  pack  follows  the  hot  blanket  pack. 

Ice  bags  may  be  used  with  the  full  pack  or  with  any  of  the  partial  packs. 
The  following  combinations  are  useful  in  the  acute  stages  of  the  diseases 
indicated: — 

APPENDICITIS — Hot  hip  and  leg  pack,  with  ice  bag  to  the  appendiceal 
region. 

PERITONITIS— Hot  hip  and  leg  pack,  or  leg  pack  only,  with  an  ice  com- 
press or  ice  cap  to  abdomen. 

PUERPERAL  INFECTIONS  AND  ACUTE  SALPINGITIS— Full  hot  blanket  pack, 
or  hip  and  leg  pack,  with  ice  to  pelvis  (suprapubic  region). 

PNEUMONIA — Hip  and  leg  pack  or  full  blanket  pack  with  cracked  ice  com- 
press over  lobe  affected. 

MENINGITIS — Hot  leg  pack,  with  ice  cravat,  ice  cap  and  ice  bag  to  base 
of  brain  and  upper  spine. 

MASTOIDJTIS— Hot  hip  and  leg  pack  or  full  blanket  pack  with  ice  cravat 
or  ice  bag  over  the  cartoid  artery,  ice  cap  to  head,  and  fomentations  to 
mastoid. 

ALVEOLAR  ABSCESS— Same  as  mastoiditis,  except  give  fomentations  to 
the  jaw. 

RENAL  CONGESTION — Hot  trunk  pack  or  full  blanket  pack  with  ice  bag 
to  lower  third  of  sternum. 

Other  combinations  will  suggest  themselves  to  the  resourceful  mind. 

ELECTROTHERMAL  PACK 

(Elec.  Pk.) 

The  electrothermal  pack  consists  of  a  specially  prepared  blanket  contain- 
ing flexible  resistance  wire.  If  it  is  to  be  used  dry,  the  body  or  part  to  be 
treated  should  be  wrapped  in  a  dry  sheet  or  thin  flannel  blanket,  and  then  in 
the  electric  blanket,  and  the  electricity  turned  on.  The  amount  of  heat 
and  consequent  effect  may  be  governed  by  the  strength  of  the  current.  If 
to  be  used  wet,  wrap  the  patient  in  a  sheet  wrung  nearly  dry  from  cold  or 
tepid  water,  and  then  in  the  electric  blanket.  The  treatment  is  concluded 
by  a  cold  mitten  friction,  spray  or  douche. 

Effects.  While  the  heat  is  not  as  intense  with  the  electric  blanket  as  with 
a  blanket  wrung  from  boiling  water,  it  is  a  gradually  increasing  heat,  and 
so,  more  desirable  for  some  purposes.  It  is  useful  for  general  sweating 
effects,  and  for  this  purpose  may  be  used  with  or  without  the  wet  sheet. 
The  dry  pack  may  be  used  where  mild  continuous  heat  is  desired,  as  after 
an  operation.  In  this  case  it  should  usually  be  applied  only  to  the  legs  or 
the  pelvis  and  legs.  A  Turkish  towel  should  be  placed  so  as  to  form  a  pad 
under  the  heels,  and  then  folded  over  the  toes.  All  bony  prominences  should 
be  similarly  covered.  The  electric  blanket  may  be  used  to  re-enforce  other 
packs  arid  so  increase  or  prolong  the  effects. 

The  electric  blanket  should  not  be  folded  sharply  at  any  place,  as  the 
wires  are  likely  to  be  broken. 


PACKS  281 

II.  WET  SHEET  PACKS 

A  wet  sheet  pack  is  a  procedure  in  which  the  body  is  wrapped  in  a  wet 
sheet,  outside  of  which  is  a  dry  blanket  covering  designed  to  regulate  the 
evaporation. 

FULL  WET  SHEET  PACK 

(W.  S.  P.) 

a.  Articles  Necessary.    Two  blankets,    a  sheet,  a   large  hand   towel,  a 
Turkish  towel,  a  pail  of  water  at  60°  to  70°  F.,  a  hot  water  bottle. 

b.  Preliminaries.    The  feet  and  entire  body    must  be  warm  before  the 
pack    is  applied.     Chilliness,  cold  skin  or  cyanosis  are  countra-indications. 
In  case  the  skin  is  not  warm,  it  is  necessary  to  give  a  hot  blanket  pack  or 
some  other  general  hot  treatment.     The  head  should  be  cooled  by  cold  com- 
presses before  entering  the  pack. 

c.  Procedure.    Place  a  double  blanket  lengthwise  of  the  treatment  table, 
with  the  edge  opposite  the  attendant  hanging  further  over  the  edge  of  the 
table  than  the  near  edge.     The  upper  end  should  be  about  eight  inches  from 
the  head  of  the  table  and  cover  the  lower  third  of  the  pillow.     Wring  the 
sheet  as  dry  as  possible  from  cold  water  and  spread  out  upon  the  blanket 
so  that  its  upper  end  will  be  a  little  below  the  upper  end  of  the  blanket. 
The  patient  now  lies  down  upon  the  wet  sheet  with  the  shoulders  three  or 
four  inches  below  the  upper  edge.     Both  arms  should  now  be  raised  while 
one  side  of  the  sheet  is  quickly  wrapped  around  the  body  drawing  it  tightly 
in  contact  at  all  places  and   tucking    the    edge    under    the    opposite    side. 
Below  the  hips  the  sheet  is  wrapped  around  the  leg  of  the  same  side.     The 
arms  are  now  lowered  and  the  opposite  side  of  the  sheet  drawn  tightly  over 
the  body  and  tucked  in.     The  sheet    is  now  folded  over  the  shoulders  and 
across  the  neck.     The  narrower  edge  of  the  blanket  is  drawn  tightly  around 
the  body  and  tucked  in  along  the  side.     The  wider  edge  is   disposed  of  in 
a  similar  manner,  pulling  it  tightly  to  bring  all  parts  in  close  contact  and 
the    extra    amount  wrapped  entirely  around  the  patient.     The  foot  end  is 
doubled  under  the  feet.     A  Turkish  towel  is  placed  about  the  neck  to  pro- 
tect the  face  and  neck  from  contact  with  the  blanket,  and  more  perfectly 
exclude  the   air.     An  additional  blanket  may  be  laid  over  the  patient  and 
tucked  in  along  the  sides  and  about  the  feet,  or  two  blankets  may  be  placed 
on  the  table  at  first. 

d.  Precautions.    The  wet  sheet  must  come  in  close  contact  with  the  body 
at  all  points.     The  dry  blanket  must  effectually  prevent  the  entrance  of  air, 
otherwise    chilling    will    result.     "Warming   up"    should   occur   promptly. 
The  feet  must  be  kept  warm  during  the  entire  treatment.     It  is  permissible 
to  place  a  hot  water  bottle  to  the  feet  to   hasten  reaction   in  case  this  is 
delayed. 

e.  Stages.    According  to  the  degree  of  warming  the  pack  undergoes,  it 
passes  through  four  stages,  viz: — cooling  or  evaporating,  neutral,  heating 
and  siveating.     It  is  often  desirable  to  prolong  the  effect  of  one  stage  so 
that  this  effect  may  predominate.     Accordingly  the  treatment  is  varied  as 
follows:— 

1.     Cooling  or  Evaporating  Wet  Sheet  Pack— Evap.  W.  S.  P.      This  is  the 


282  TECHNIQUE  OF  HYDROTHERAPY 

first  stage  of  the  pack  before  the  sheet  has  been  warmed  to  the  tempera- 
tu$e  of  the  body.  It  requires  from  five  to  twelve  minutes  to  accomplish 
this.  If  at  the  end  of  this  time  the  sheet  is  removed  and  another  applied, 
the  effect  is  intensified,  or  the  blanket  may  be  folded  back  and  cold  water 
sprinkled  on  the  patient  over  the  wet  sheet.  In  the  case  of  vigorous  patients 
the  dry  coverings  may  be  omitted  entirely,  considerable  water  left  in  the 
sheet,  and  the  patient  fanned  to  hasten  evaporation,  more  water  being 
sprinkled  on  the  sheet  as  soon  as  it  is  warmed  slightly. 

Effects.  The  evaporating  wet  sheet  pack  is  a  powerful  antipyretic  meas- 
ure. It  is  useful  in  typhoid  fevers  and  in  other  continued  fevers  where 
repeated  antipyresis  is  necessary.  It  is  usually  best  not  to  remove  the  pack 
for  renewal  but  sprinkle  on  more  cold  water.  As  in  the  use  of  the  cold  tub 
bath  in  typhoid  fever,  rubbing  is  necessary  if  the  water  is  very  cold  or  the 
sheet  sprinkled  frequently.  This  is  known  as  the  rubbing  wet  sheet  pack. 
Percussion  should  not  be  used.  The  greater  the  amount  of  water  applied 
to  the  body,  the  stronger  are  the  antipyretic  effects,  and  consequently  the 
quicker  is  the  temperature  of  the  patient  reduced. 

If  desirable,  the  sheet  may  be  wrung  from  hot  water,  the  coverings  being 
omitted.  This  is  spoken  of  as  a  hot  evaporating  sheet.  It  is  useful  where 
slight  chilliness  exists.  This  treatment  is  not  only  antipyretic  but  also  les- 
sens heat  production  because  of  the  initial  heat  and  the  consequent  atonic 
reaction. 

2.  Neutral  Wet  Sheet  Pack— Neut.  W.  S.  P.  The  neutral  stage  begins 
when  the  temperature  of  the  pack  reaches  or  slightly  exceeds  the  tempera- 
ture of  the  skin,  viz., — about  94°  F.  It  may  be  prolonged  by  removing  all 
but  one  or  two  dry  coverings  after  the  warming  up  has  well  begun.  This 
allows  of  sufficient  evaporation  to  prevent  the  accumulation  of  heat  above 
the  temperature  of  the  body.  The  protection  must  be  uniform  and  the 
entrance  and  circulation  of  air  prevented. 

Effects.  The  effects  of  the  neutral  wet  sheet  pack  have  been  considered 
under  the  treatment  of  insomnia.  A  neutral  temperature  is  secured  the 
same  as  in  the  neutral  bath.  The  marked  sedative  effects  of  the  neutral 
pack  are  due  more  to  the  derivation  secured  than  to  the  neutral  tempera- 
ture. In  normal  sleep  there  is  a  lessening  of  the  amount  of  blood  in  the 
brain  and  a  local  decrease  of  blood  pressure.  The  neutral  pack  brings  about 
these  changes  and  so  aids  in  inducing  relaxation  and  sleep. 

If  the  pack  is  removed  before  sleep  is  produced,  uncover  one  part  at  a 
time,  drying  thoroughly  and  wrapping  it  in  a  warm  dry  sheet,  or  entirely 
remove  the  pack  and  immediately  wrap  the  patient  in  a  warmed  sheet,  fin- 
ishing the  drying  as  quickly  as  possible. 

If  the  pack  is  removed  after  the  patient  has  slept,  conclude  the  treat- 
ment by  a  wet  hand  rub  or  cold  mitten  friction  according  to  the  degree  of 
tonic  effect  desired. 

The  neutral  wet  sheet  pack  is  also  of  use  in  the  delirium  of  fevers,  in  mania, 
epilepsy,  chorea,  infantile  convulsions  and  various  other  agitative  neuroses. 

:J.  Healing  Wet  Sheet  Pack — Heat.  W.  S.  P.  The  heating  stage  begins 
when  the  warming  of  the  pack  raises  the  skin  temperature  slightly  above 
its  usual  degree;  it  ends  at  the  beginning  of  general  perspiration  which 
marks  the  establishment  of  a  full  reaction.  For  tonic  effects  the  pack 


PACKS  283 

should  continue  about  twenty  minutes.  When  the  stage  of  a  pack  is  not 
prescribed,  this  treatment  is  intended. 

Effects.  Tonic  and  heating  effects  are  secured  by  it.  These  may  be  pro- 
longed by  applying  cold  water  to  the  head  and  neck  continuously  so  as  to 
check  extreme  sweating.  The  chief  effect  of  the  heating  wet  sheet  pack 
is  the  production  of  derivation.  The  reaction  and  heating  up  of  the  skin 
caused  by  the  accumulation  of  body  heat,  congests  the  skin  and  so  lessens 
the  amount  of  blood  in  the  internal  organs. 

The  heating  pack  possesses  quite  a  range  of  usefulness  in  securing  mild 
tonic  and  derivative  effects.  It  may  be  used  in  anemia,  chlorosis,  infectious 
fevers,  convalescence  from  fever,  neurasthenia,  diabetes,  etc. 

4.  Eliminative  or  Sweating  Wet  Sheet  Pack— Sweat.  W.  S.  P.  The  pro- 
duction of  general  perspiration  marks  the  beginning  of  the  sweating  stage. 
The  sweating  may  be  increased  or  prolonged  by  additional  coverings,  hot 
water  bottles  placed  within  the  folds  of  the  dry  blanket,  or  the  drinking  of 
hot  water  or  lemonade  at  intervals.  The  cold  compresses  on  the  head 
should  not  be  very  cold  or  renewed  too  frequently  as  this  depresses  the 
thermogenic  centers  and  prevents  sweating. 

Effects.  The  sweating  wet  sheet  pack  is  a  very  valuable  eliminative  and 
spoliative  measure.  It  is  one  of  the  most  useful  means  in  the  treatment  of 
the  transient  fevers  of  infants  and  children,  in  capillary  bronchitis,  colds 
and  the  grippe. 

For  purposes  of  elimination  it  is  useful  in  such  toxemias  as  alcohol  and 
nicotine  poisoning,  lead  poisoning  and  various  autointoxications.  It  is  use- 
ful in  chronic  Bright's  disease  and,  if  not  too  prolonged,  it  may  be  used  in 
jaundice. 

For  spoliative  purposes  it  is  useful  in  obesity  and  obese  rheumatics. 

HALF  PACK  OR  HEATING  TRUNK  PACK 
(1-2  Pk.) 

The  heating  trunk  pack  is  given  in  the  same  manner  as  the  heating  wet 
sheet  pack,  except  that  it  includes  the  trunk  and  hips  only,  the  arms  and 
legs  being  excluded.  A  full  blanket  should  be  spread  out  on  the  treatment 
table  and  over  this  placed  a  sheet  wrung  from  water  at  60°  F.  and  folded  to 
the  proper  width  to  include  the  trunk  and  hips.  The  patient  now  lies  on 
the  wet  sheet  and  it  is  drawn  tightly  about  the  body.  The  dry  blanket  is 
next  folded  over  so  as  to  bring  the  wet  sheet  in  close  contact  with  the  skin 
surface.  A  moderate  hot  foot  bath  is  given  at  the  same  time  and  continued 
during  the  treatment.  The  dry  blanket  should  be  laid  loosely  over  the  limbs. 
The  pack  and  the  patient  should  not  be  so  thoroughly  covered  as  to  produce 
general  perspiration.  It  is  well  to  have  a  dry  sheet  or  towels  intervene 
between  the  blanket  and  the  patient  at  all  places  not  covered  by  the  wet 
pack.  For  this  purpose  a  dry  sheet  may  be  spread  out  on  the  dry  blanket 
before  the  wet  sheet  is  placed  for  the  trunk.  The  treatment  should  last 
about  twenty  or  twenty-five  minutes  and  be  concluded  with  a  cold  mitten 
friction  or  an  alternate  spray  douche  to  the  parts  covered  by  the  pack  and 
to  the  feet  and  legs. 

The  effects,  though  less  pronounced,  are  in  general  the  same  as  those  of  the 
hot  and  heating  trunk  pack,  q.  v. 


284  TECHNIQUE  OF  HYDROTHERAPY 

HOT  AND  HEATING  TRUNK  PACK 
(H.  &  Heat.  Tr.  Pk.) 

This  treatment  is  the  same  as  that  previously  described  under  the  Winter- 
nitz  coil. 

A  single  blanket  is  placed  crosswise  of  the  treatment  table  or  bed  so  that 
the  upper  edge  may  reach  well  up  under  the  arms.  A  sheet  doubled  (in 
case  of  feeble  patients  a  single  thickness)  to  a  width  which  will  reach  from 
the  axilla  to  below  the  hips  is  now  wrung  from  cold  water  and  placed  over 
the  blanket.  The  patient  now  lies  down  on  this  and  while  both  arms  are 
raised,  one  end  of  the  wet  sheet  is  pulled  tightly  across  and  around  the 
trunk.  Over  the  epigastric  and  umbilical  regions  outside  of  the  sheet, 
place  a  three-quart  hot  water  bottle  half  filled  with  water  at  135°  to  140°  F. 
Wrap  the  other  end  of  the  sheet  about  the  trunk  over  the  hot  water  bottle 
and  cover  snugly  with  a  dry  blanket,  folding  over  one  end  at  a  time.  A 
Winternitz  coil  or  an  electric  pad  may  be  used  in  place  of  the  hot  water 
bottle.  Continue  the  treatment  from  forty  minutes  to  two  hours.  General 
sweating  should  not  be  produced.  It  may  be  begun  half  and  hour  before 
the  meal.  Take  the  patient  out  with  a  cold  mitten  friction  or  an  alternate 
spray  douche  to  the  abdomen  and  spine. 

Effects.  The  hot  and  heating  trunk  pack  is  the  most  efficient  hydrothera- 
peutic  measure  for  the  treatment  of  digestive  disturbances.  It  promotes 
gastric  secretion  and  gastric  digestion.  Liver  activity  and  intestinal  diges- 
tion proceed  more  normally.  Excessive  or  reverse  peristalsis  is  checked, 
and  in  decreased  gastric  motility,  stomach  movements  are  hastened.  Because 
of  more  perfect  digestion  and  more  normal  peristalsis,  gas  formation  is 
markedly  decreased  or  entirely  checked. 

The  hot  and  heating  trunk  pack  is  indicated  in  persistent  vomiting,  dys- 
pepsia, flatulence,  splanchnic  neurasthenia,  chronic  congestion  of  the  liver 
and  in  anemia  of  the  liver. 

In  cases  of  almost  complete  arrest  of  gastric  digestion  or  in  persistent 
vomiting,  the  pack  should  be  applied  about  twenty  minutes  before  the  meal 
and  continued  for  two  or  three  hours.  A  cold  mitten  friction  should  be 
given  at  the  close.  The  feet  should  be  warmed  by  a  hot  foot  bath  before 
the  treatment  and  kept  warm  during  the  treatment.  The  hot  foot  bath 
may  be  continued  while  the  treatment  lasts,  if  this  is  not  over  thirty  min- 
utes; otherwise  it  is  well  to  dry  the  feet  and  wrap  them  in  dry  flannel  so 
that  the  patient  may  rest  more  perfectly.  For  further  details  of  the  uses 
and  effects,  see  treatment  of  atonic  dyspepsia. 

HEATING  PELVIC  PACK 
(Heat.  Pelv.  Pk.) 

On  the  treatment  table  spread  a  blanket  as  for  a  full  pack.  Next  fold  a 
single  blanket  to  form  a  square  and  then  diagonally  to  form  a  triangle. 
Arrange  this  on  the  large  blanket  so  that  the  base  is  upward  and  the  apex 
downward  where  it  may  be  folded  about  the  pelvis  when  the  patient  reclines. 
Over  this  place  a  sheet  similarly  folded  and  wrung  nearly  dry  from  water 
at  60°  F.  The  patient  now  reclines,  and  with  legs  flexed  and  knees  separated, 
the  apex  of  the  wet  sheet  is  brought  into  close  contact  with  the  perineum 
and  spread  over  the  abdomen.  With  legs  extended,  each  lateral  angle  of 


SPRAYS  AND  DOUCHES  285 

the  wet  sheet  is  drawn  down  tightly  across  the  hips,  lower  abdomen  and 
upper  thigh.  The  triangular  piece  of  dry  flannel  is  now  applied  in  the  same 
manner,  and  the  patient  covered  with  the  large  blanket.  Continue  the 
pack  twenty  or  thirty  minutes. 

Effect.  The  heating  pelvic  pack  is  a  mild  tonic  and  derivative  means  the 
same  as  the  heating  trunk  pack.  It  helps  to  equalize  the  pelvic  circulation 
and  reduce  congestions  of  the  pelvic  viscera.  It  relaxes  hypertonic  muscles 
and  stimulates  atonic  muscles.  The  heating  pelvic  pack  is  not  used  as  much 
as  the  sitz  bath  in  the  treatment  of  pelvic  disorders.  It  is  indicated  in 
chronic  congestions  of  the  pelvic  organs,  amenorrhea,  chronic  metritis,  back- 
ache, chronic  colitis,  etc.  When  used  ki  cases  of  much  pelvic  pain  or  other 
pelvic  distress,  a  hot  water  bottle  or  coil  should  be  placed  next  to  the  wet 
sheet  over  the  lower  abdomen  and  suprapubic  region  in  the  same  manner  as 
in  the  hot  and  heating  trunk  pack. 


SPRAYS  AND  DOUCHES 

A  spray  or  douche  consists  in  the  projection  of  one  or  more  columns  of 
water  against  the  body.  Many  different  appliances  are  used  in  giving  these 
treatments.  They  possess  such  a  wide  range  of  adaptability  that  almost  any 
desired  effect  may  be  produced  by  them.  For  this  reason  both  the  physi- 
cian and  the  nurse  should  become  thoroughly  proficient  in  the  use  of  the 
spray  and  douche  controller.  The  water  supply  to  the  controller  should  come 
direct  from  a  hot  and  a  cold  water  tank  by  pipes  entirely  independent  of  all 
other  fixtures,  and  no  other  faucets  or  fixtures  should  be  attached  to  these 
mains.  The  most  perfectly  constructed  controller  will  fail  to  give  satisfac- 
tory results  unless  this  rule  is  observed. 

SHOWER  BATH 

(Sh.) 

A  shower  or  rain  bath  consists  in  the  projection  of  water  in  many  fine 
streams  falling  upon  the  patient.  In  the  shower  bath  gravitation  is  the 
principal  force  utilized;  the  effect  however  is  often  enhanced  by  added  pres- 
sure. The  perforated  disc  from  which  the  water  descends  should  be  about 
six  inches  in  diameter  and  from  ten  to  sixteen  inches  above  the  patient's 
head.  There  should  be  sufficient  force  to  cause  the  water  to  flow  rapidly. 
The  room  should  be  very  small  and  protected  from  drafts.  See  that  the 
patient's  feet  are  warm  before  entering  the  shower.  If  the  wetting  of  the 
hair  is  objectionable,  as  with  women,  protect  by  a  rubber  or  mackintosh  cap. 
Turn  on  the  shower  and  adjust  to  the  proper  temperature  before  the  patient 
enters. 

In  making  sudden  changes  in  temperature  see  that  the  vents  or  discharg- 
ing outlets  are  opened  during  the  change,  otherwise  difficulty  will  be  experi- 
enced in  securing  an  instantaneous  change,  or  the  hot  water  because  of  added 
pressure  may  crowd  out  the  cold. 

1.  Hot  Shower — H.  Sh.  Begin  the  hot  shower  at  100°  to  105°  F.,  and 
gradually  raise  the  temperature  to  from  110°  to  115°  F.,  or  slightly  above. 
Time — thirty  seconds  to  two  minutes.  It  is  used  chiefly  as  a  preparation 


286  TECHNIQUE  OF  HYDROTHERAPY 

for  the  cold  shower  or  douche.  It  may  be  necessary  to  use  a  cold  compress 
to  the  head  during  the  hot  shower.  If  only  a  hot  shower  is  prescribed,  cool 
rapidly  to  90°  or  85°  F.;  and  dry  quickly  with  sheet  and  towels,  finishing  by 
fanning  the  patient  with  a  dry  sheet. 

2.  Cold  or  Cool  Shower — C.  Sh.  The  cold  shower  is  usually  preceded  by 
a  hot  shower.  When  the  patient  has  been  warmed,  lower  the  temperature 
rapidly  from  hot  to  the  limit  of  tolerance  or  reactive  ability  of  the  patient. 
Cool— 70°  to  90°  F.  Cold— 55°  to  70°  F.  At  first,  before  the  patient  becomes 
accustomed  to  the  shower,  the  upper  limits  should  be  utilized  and  in  each 
succeeding  treatment  the  temperature  lowered  by  1°  or  2°  daily  and  the 
time  prolonged  to  from  one-half  to  Three  or  more  minutes.  Effects — tonic. 

;j.  Neutral  Shower — Neut.  Sh.  In  giving  a  neutral  shower,  begin  with 
the  water  at  100°  F.,  and  very  gradually  lower  it  to  97°  to 94°  F.  The  treat- 
ment should  last  from  three  to  five  minutes.  The  patient  should  be  dried 
quickly  without  percussion  or  unnecessary  friction.  Effects — sedative. 

4.  Graduated  Shower — Grad.  Sh.      After  a  prolonged  or  vigorous  sweat- 
ing bath,  it  is  desirable  to  lower  the  temperature  of  the  shower  slowly  for 
gradual  cooling  and  to  abstract  as  much  heat  from  the  body  as  possible  with- 
out producing  a  decided  thermic  reaction.      Apply  a  cold  compress  to  the 
head  before  the  patient  leaves  the  hot  bath.     Begin  at  108°  to  110°  F.,  quickly 
raising  the  temperature  to  115°  or  118°  F.      Maintain  this  until  the  patient 
feels  well  warmed  and  is  ready  to  welcome  the  cold.      Gradually  lower  the 
temperature  to  between  80°  and  90°  F.     Time — two  to  six  minutes.    .Dry  as 
quickly  as  possible  with  sheets  and  towels  and  see  that  the  patient  is  not 
exposed  to  cold  air  or  drafts  for  at  least  an  hour  after. 

5.  Alternate  Hot  and  Cold  Shower — H.  &  C.  Sh.      To  obtain  the  best  results 
the  changes  must  be  abrupt  from  hot  to  cold.      This  can  only  be  secured  by  a 
properly  constructed  spray  and  douche  apparatus,  having  an  alternating  lever 
or  other  alternating  appliance,  and  supplied  by  pipes  with  no  other  outlet 
and  coming  direct  from  hot  and  cold  water  tanks.     With  vent  pipes  open  on 
both  sides  of  the  apparatus,  regulate  the  hot  to  108°  to  110°  F.,  allowing  it 
to  run  through  the  shower.      Regulate  the  cold  to  the  prescribed  tempera- 
ture, say  65°.      The  patient  may  now  enter  the  hot  shower  which  is  raised 
to  the  limit  of  tolerance  and  continued  about  one  minute  or  until  the  patient 
is  thoroughly  warmed.       Switch  the  alternating  lever  to  the  cold  and  con- 
tinue ten  to  twenty  seconds.     Reverse  to  hot  again  for  one-half  to  one  min- 
ute, then  follow  by  a  second  cold  and  so  on  for  three  complete  changes  of 
hot  and  cold,  closing  with  the  cold  and  drying  as  usual. 

Precautions.  If  the  vents  are  closed  the  hot  will  "run  up"  when  not  in 
use,  since  the  hot  water  is  usually  at  a  higher  pressure  and  forces  back  the 
cold.  If  this  occurs,  when  the  hot  is  turned  on,  the  patient  is  likely  to  be 
burned.  It  is  best  to  warn  the  patient  of  the  change  from  hot  to  cold  so  as 
to  avoid  undesirable  nerve  shock  in  the  case  of  nervous  patients. 

Effects.  The  alternate  hot  and  cold  shower  is  a  vigorous  tonic  and  stimu- 
lant measure.  To  many  patients  it  is  more  agreeable  than  the  needle  spray. 

SPRAYS 

(Spr.) 

A  spray  bath  consists  in  the  simultaneous  projection  of  water  against  all 


SPRA  YS  AND  DOUCHES  287 

parts  of  the  body  by  horizontal  jets  surrounding  the  patient.  For  this  pur- 
pose four  upright  pipes,  arranged  in  a  square  and  having  perforations  on  the 
side  of  each  toward  the  center,  are  used.  Since  these  pipes  are  stationary, 
it  is  necessary  to  have  a  short  patient  stand  on  a  sto6l  so  that  the  water 
may  not  strike  the  face.  A  tall  patient  must  bend  the  knees  in  order  to 
have  the  spray  cover  the  entire  trunk.  To  overcome  this  inconvenience 
and  to  spread  the  streams  of  water  still  more,  rosettes  may  be  arranged 
along  the  pipes  at  intervals  of  ten  or  twelve  inches,  the  upper  row  being 
movable.  The  effects  and  uses  of  the  spray  are  the  same  as  those  of  the 
shower  with  the  possible  difference  that  the  application  is  somewhat  more 
general  and  there  is  more  or  less  mechanical  stimulation  due  to  percussion 
or  pricking  of  the  jets.  This  is  greater  as  the  pressure  is  increased  by  the 
full  opening  of  the  spray  valve.  Treatments  are  given  in  the  same  manner 
as  with  the  shower. 

DOUCHES 
(D.) 

The  douche  is  a  local  application  consisting  of  a  single  or  multiple  column 
of  water  directed  against  some  part  of  the  body.  It  is  certainly  one  of  the 
most  useful  of  all  hydrotherapeutic  measures.  The  effect  of  almost  every 
other  form  of  treatment  commonly  given  to  ambulatory  patients  may  be 
approached  and  usually  exceeded  by  the  douche  in  the  hands  of  one  skilled 
in  its  application. 

The  necessary  attachments  are  not  numerous.  These  should  consist  of  a 
straight  nozzle  with  or  without  a  center  needle  for  breaking  and  spreading 
the  jet;  a  spray  nozzle  like  the  sprinkler  of  a  watering  pot  except  that  the 
perforated  dish  should  have  a  nearly  flat  face;  a  fan  douche  nozzle,  a  mov- 
able flat  piece  attached  to  the  straight  nozzle  will  answer  the  same  purpose; 
a  stool  with  an  open  seat  and  attached  up-shot  spray  douche  nozzle  for  adminis- 
tering the  perineal  douche. 

The  jet  nozzle  is  used  whenever  percussion  effects  are  desired.  The  pres- 
sure may  be  increased  by  opening  the  valve  wide,  or  by  turning  into  the 
nozzle  compressed  air  from  a  separate  tube.  Where  a  percussion  douche 
(Perc.  D.)  is  ordered  the  jet  is  understood.  Both  cold  and  percussion  pro- 
duce a  decided  thermic  reaction  and  increase  the  vigor  and  permanency  of 
the  circulatory  reaction.  The  spray  douche  is  useful  where  percussion  is 
not  desirable.  The  jet  douche  may  be  "broken"  by  placing  the  finger  so  as 
to  interfere  with  the  stream.  It  then  resembles  the  spray  douche  in  effect. 
The  effects  in  general  vary  according  to  the  mass,  pressure  and  tempera- 
ture of  the  column  of  water  striking  the  body. 

In  prescribing  douches  the  form  of  nozzle  desired  should  be  specified  and 
such  designations  used  as  will  indicate  the  part  of  the  body  to  be  treated. 
The  cerebral  circulation  will  be  steadied  and  better  general  and  local  results 
obtained  if  all  applications  of  the  douche  begin  and  end  with  the  feet.  The 
patient  should  dip  the  hands  in  cold  water  and  bathe  his  face  before  the 
douche  is  applied.  In  applying  the  douche  some  definite  plan  should  be 
learned  and  systematically  followed,  making  changes  when  necessary  for  the 
particular  case  and  condition  in  hand.  In  order  to  guard  against  burning, 
always  keep  the  index  finger  of  the  hand  holding  the  douche  in  contact 
with  the  stream  of  water  as  it  emerges  from  the  nozzle.  This  should  be 


done  with  the  most  perfect  of  appliances  and  even  when  no  trouble  at  all  is 
anticipated.  Keep  a  steady  hand,  apply  the  douche  accurately  to  the  part 
to  be  treated  and  have  the  thermometers  under  constant  observation. 

The  following  are  the  general  directions  for  douches  of  different  tempera- 
tures. In  giving  these  any  form  of  nozzle  may  be  used  and  any  portion  of 
the  body  treated.  To  enumerate  all  the  possible  variations  and  the  particu- 
lar surface  and  reflex  or  hydrostatic  effects  derived  from  each  would  require 
a  small  volume  in  itself.  As  in  all  hydrotherapeutic  procedures,  practical 
instruction  is  of  far  more  value  than  any  amount  of  text  description  and 
text  illustration.  Such  designations  as  the  Scotch  douche,  Charcot  douche, 
etc.,  are  non-descriptive  and  as  far  as  possible  should  be  dropped  from 
hydrotherapeutic  nomenclature. 

1.  Hot  Douche — H.  D.      Where  the  hot  douche  alone  is  used  it  is  given 
for  a  relatively  long  time — two  to  five  minutes,  at  a  temperature  of  105°  to 
125°  F.,  and  followed  by  a  very  brief  application  of  cold,  five  to  fifteen  sec- 
onds, temperature  60°  to  90°  F.     This  is  supposed  to  be  just  long  enough  to 
remove  from  the  skin  the  heat  communicated  by  the  hot  douche.     The  prin- 
ciple is  identical  with  that  of  the  revulsive  douche  except  that  in  the  latter, 
three  or  more  changes  are  employed,  while  here  only  one  is  given. 

Effects.  The  hot  douche  produces  dilatation  of  the  cutaneous  vessels  and 
so  where  applied  to  a  considerable  area,  effective  derivation  is  secured. 
Where  applied  to  a  small  area,  the  dilatation  of  the  vessels  in  the  deep  part 
through  a  reflex  channel  may  equal  or  exceed  the  hydrostatic  effect.  Per- 
cussion intensifies  the  reflex  effect. 

The  hot  douche  is  used  for  the  relief  of  pain,  irritation,  neuralgia,  sciatica, 
etc.  In  these  cases  percussion  is  undesirable.  The  effect  of  the  combina- 
tion of  a  hot  with  a  cold  douche  is  given  below. 

2.  Neutral  Douche— Neut.  D.     Temperature— 94°  to  97°  F.     Time— three 
to  six  minutes.      The  broken  jet  or  spray  douche  are  used  since  sedative 
effects  are  sought.      The  neutral  spray  douche  is  especially  beneficial  when 
given  to  the  spine.     No  force  should  be  used  and  the  patient  should  sit  on  a 
stool  with  the  back  to  the  operator. 

3.  Cold  Douche— C.  D.      Temperature— 55°  to  70°  F.      The  cold  douche  is 
seldom  given  alone,  but  when  not  preceeded  by  hot,  the  percussion  jet  should 
be  used.     Given  in  this  way,  vigorous  fluxion  is  produced  in  the  part  treated 
with  a  corresponding  derivation  from  other  parts. 

4.  Revulsive  Douche — Rev.  D.      Three  or  more  abrupt  changes  from  hot 
to  cold  are  used.     Temperature  of  the  hot — 112°  to  115°  F.     Time — a  half  to 
two  minutes.      Temperature  of  the  cold — 55°  to  70°  F.      Time — five  to  ten 
seconds.       Unless  given  with    high    pressure,    (percussion)  the    reaction -is 
chiefly  circulatory.      Percussion  is  not  usually  desirable  with  the  revulsive 
douche. 

Effects.  It  will  be  noted  that  the  duration  of  the  hot  is  exceedingly  brief 
as  compared  with  the  duration  of  the  cold.  In  this  item  lies  the  difference 
between  the  revulsive  and  the  alternate  hot  and  cold  douche.  The  effect  of 
the  revulsive  douche  is  chiefly  circulatory  and  greater  in  the  surface  blood 
vessels  than  in  the  deep  part,  i.  e.,  the  reflex  effect  is  not  prominent.  The 
surface  effect  is  that  of  fluxion  and  if  a  sufficient  surface  is  covered  by  the 


SPRAYS  AND  DOUCHES  289 

treatment,  a  hydrostatic  (derivative)  effect  upon  other  parts  is  produced. 

The  revulsive  spray  douche  is  especially  applicable  to  the  chest,  abdomen 
and  over  the  liver  and  spleen,  also  to  the  spine,  pelvis  and  perineum. 

5.  Alternate  Hot  and  Cold  Douche— H.  &  C.  D.  The  method  of  giving  the 
alternate  douche  is  the  same  as  for  the  revulsive  douche  except  that  the  cold 
application  is  of  greater  duration,  being  from  one-third  the  duration  of  the 
hot  to  equal  with  it,  so  that  where  the  hot  is  given  for  one  minute  the  cold 
should  last  twenty  seconds  to  one  minute,  depending  upon  the  reactive 
powers  of  the  patient.  Percussion  (H.  &  C.  Perc.  D.)  adds  much  to  the 
vigor  and  permanency  of  the  reaction. 

Effects.  The  alternate  hot  and  cold  douche  produces  vigorous  fluxion  in 
the  surface  treated.  When  percussion  is  used  the  reflex  effects  become 
prominent  especially  if  the  douche  is  applied  to  only  one  or  two  parts  of  the 
body.  As  a  general  treatment,  for  example,  the  alternate  hot  and  cold  per- 
cussion douche  to  the  spine  and  legs,  powerful  tonic  and  stimulant  effects 
are  produced.  The  alternate  percussion  douche  to  the  feet  and  legs  is  a 
most  efficient  derivative  measure,  especially  when  preceded  by  the  hot  leg 
bath.  The  extreme  fluxion  it  induces  in  the  feet  and  legs  produces  a  decided 
and  enduring  derivation. 

The  following  list  of  treatments,  which  may  be  given  by  means  of  the 
spray  and  douche  apparatus,  will  help  to  show  the  technique  and  something 
of  the  principles  envolved  in  the  effects  desired. 

As  A  GENERAL  TONIC— H.  &  C.  Perc.  D.  to  spine,  legs  and  feet. 

To  PRODUCE  REACTION  IN  ONE  UNACCUSTOMED  TO  COLD— H.  Sh.  or  Spr. 
with  C.  Perc.  D.  to  spine  and  legs  at  same  time. 

To  RELIEVE  CONGESTIVE  HEADACHE— H.  &  C.  Perc.  D.  to  feet  with  C. 
Com  p.  to  head. 

CONGESTION  OF  THE  LIVER— Rev.  D.   (Perc.  or  Spr.)  over  hepatic  area. 
SCIATICA — Prolonged  H.  D.  over  sciatic  nerve. 
VARICOSE  ULCERS— H.  &  C.  Spr.  D.  to  legs,  six  to  ten  changes. 
HYPOCHLORHYDRIA — Rev.  D.  to  epigastrium  and  mid-dorsal  spine. 
LUMBAGO— H.  &  C.  Perc.  D.  to  lower  back. 

LOCOMOTOR  ATAXIA  AND  OTHER  FLACCID  PARALYSES— Rev.  or  Alt.  D.  to 
spine. 

SPASTIC  SPINAL  PARALYSIS— Prolonged  Neut.  Spray  D.  to  spine. 

CHOREA— Neut.  D.  Shr.  or  Spr. 

RENAL  CONGESTION  (CHRONIC)— H.  &  C.  Perc.  D.  to  lower  third  of  ster- 
num and  over  kidneys  at  back. 

CHRONIC  PELVIC  CONGESTIONS— C.  D.  to  lumbar  and  sacral  regions. 

AMENORRHCEA — Short  C.  Perc.  D.  to  feet. 

SPECIFIC  URETHRITIS,  PRURITIS  ANI,  CHRONIC  PROSTATITIS,  ETC.— Rev. 
Spr.  D.  to  perineum  (called  also  "up  spray"). 

CHRONIC  PLEURISY,  UNRESOLVED  PNEUMONIA,  ETC.— H.  &  C.  Spr.  D.  to 
chest  over  area  affected  (use  no  force)  followed  by  H.  &  C.  Perc.  D.  to  feet 
and  legs. 


290  TECHNIQUE  OF  HYDROTHERAPY 

AFFUSIONS 

An  affusion  is  the  pouring  of  water  from  a  convenient  receptacle  over  the 
entire  body  or  a  portion  thereof.  Since  the  perfection  of  spray  and  douche 
apparatus,  the  affusion  has  fallen  into  disuse  in  institutions  equipped  with 
such  appliances.  However,  the  pour  has  certain  advanages  which  are  not 
outweighted  by  the  greater  convenience  of  more  complicated  appliances. 
The  flow  of  a  considerable  volume  of  water  over  a  part  has  a  somewhat 
different  effect  from  a  douche.  Since  it  may  be  used  in  any  home,  it  has  a 
wide  range  of  usefulness. 

1.  Pail  Pour  or  General  Affusion — P.  P.      The  patient  should  be  warm 
beforehand.     If  given  in  a  bath  tub  he  may  sit,  or  if  given  while  standing,  the 
feet  should  be  in  a  tub  of  hot  water,  and  in  either  case  apply  a  cold  cephalic 
compress.      Prepare  three  pails  of  water  at  different  temperatures,  accord- 
ing to  the  effect  desired.     These  should  be  poured  over  the  shoulders,  using 
the  warmest  first.      For  a  mild  tonic  employ  pails  of  water  at  100°,  90°  and 
85°  or  80°  F.,  respectively.      If  the  patient  has  just  come  from  a  warm  bath 
of  some  sort,  a  lower  temperature  may  be  used  for  the  first  pail  and  the 
others  correspondingly  lower,  or  only  two  pails  used.      In  succeeding  treat- 
ments lower  the  degree  of  the  applications  until  water  at  50°  to  60°  is  used 
for  the  third  pail.     Rub  the  patient  vigorously  after  the  last  pail  and  dry  as 
from  spray  or  shower.     The  pail  pour  is  conveniently  used  after  the  tub  or 
slab  shampoo,  salt  glow,  etc.      A  cold  pail  pour  to  the  hips  is  given  after 
the  hot  half- bath  and  the  hot  sitz  bath  for  revulsive  effects. 

2.  Local  Affusions.      These    may  be  designated   according  to   the   part 
treated  and  the  temperature  of  the  application.    A  hot  affusion  relieves  pain. 
The  circulatory  excication  soon  gives  way  to  a  tonic  reaction.      A  neutral 
affusion,  especially  to  the  spine,  is  sedative.      A  cold  affusion,  if  short,  is 
stimulating  and  tonic;  if  prolonged,  it  reduces  congestion  and  inflammation, 
stimulating  phagocytosis.      A  long  cold  pour  to  the  head  is  strongly  anti- 
pyretic.    The  alternate  hot  and  cold  pour  is  a  powerful  stimulant  and  tonic, 
producing  fluxion  in  the  part  treated,  with  derivation  from  other  parts.     It 
produces  a  decided  local  leucocytosis  and  stimulates  phagocytosis.     Because 
of  these    effects  it  is  a  very  useful    measure  in  treating  an  infected    part 
where    it   is   impossible  or  undesirable  to  completely   immerse  the  part  in 
water. 

In  giving  an  affusion  to  the  spine,  the  patient  may  sit  on  the  edge  of  a 
bath  tub  or  on  a  stool  in  the  tub.  In  giving  a  pour  to  the  arm,  hand,  foot, 
etc.,  the  part  may  be  held  over  a  small  tub  while  the  water  is  poured  from 
a  pail  or  large  pitcher.  To  treat  the  head  by  a  pour  the  patient  should  lie 
on  a  cot  with  head  resting  over  the  end  and  a  tub  underneath.  In  giving 
local  atfusions  tne  water  should  fall  a  distance  of  three  or  four  inches  to  one 
or  two  feet  according  to  the  part  treated  and  effects  desired. 

ENEMATA 

An  enema  is  an  injection  of  fluid  into  the  rectum. 

General  Directions: — 
a.     Articles  Necessary.     An  enema  can  with  a  capacity  of  one-half  to  two 


ENEMATA  291 

gallons  or  a  fountain  syringe  or  combination  bag. 

Five  or  six  feet  of  rubber  tubing  with  cut-off. 

A  glass  or  hard  rubber  enema  tube. 

A  disinfectant  solution  for  the  enema  tube.  One  to  three  per  cent  lysol 
acts  both  as  a  disinfectant  and  a  soap  for  cleansing.  A  water  thermometer. 
Toilet  paper. 

If  given  in  the  room,  there  should  be  in  addition  a  standard  or  hook  for 
suspending  the  enema  can,  a  bed  pan,  slop  jar  and  several  newspapers. 

In  the  treatment  room  shelves  or  hooks  are  most  convenient  for  holding 
the  can,  they  should  be  so  arranged  that  the  elevation  of  the  enema  can 
may  be  varied  from  two  to  one-half  feet  to  four  feet  above  the  patient. 

b.  Procedure.  Fill  the  enema  can  with  from  two- to  six  quarts  of  water 
at  the  proper  temperture  (test  with  a  thermometer). 

The  patient  should  be  warm,  especially  the  feet.  All  clothing  not  removed 
should  be  loose. 

Position  of  patient — Dorsal,  sitting,  right  Sims  or  knee-chest. 

Release  the  cut-off  and  allow  the  water  to  run  until  the  stream  is  at  the 
same  temperature  as  the  water  in  the  can.  Close  cut-off  and  lubricate  the 
enema  tube,  being  careful  to  wash  it  beforehand,  removing  the  disinfectant 
solution. 

The  patient  should  insert  the  tube  unless  very  ill  or  unable  to  do  so. 
Instruct  the  patient  to  take  as  much  water  as  possible.  To  make  it  easier 
to  do  this,  stop  the  flow  by  pinching  the  tube  two  or  three  times  during  the 
taking  of  the  enema.  Close  cut-off  and  remove  the  tube.  If  possible  the 
patient  should  retain  the  water  a  few  minutes  before  discharging. 

Repeat  until  a  thorough  bowel  movement  is  secured  or  other  desired  result 
is  obtained. 

I.  PLAIN  WATER  ENEMATA 

RECTAL  INJECTION  OR  ENEMA 

(E.  or  En.) 

In  the  ordinary  enema  the  desired  amount  of  fluid  is  injected,  allowed  to 
remain  a  short  time  and  then  passed.  The  procedure  is  different  from 
rectal  irrigation,  in  which  there  is  a  continuous  inflow  and  outflow  of  fluid. 

1.  Hot  Enema — H.  En.     The  temperature  of  the  hot  enema  should  vary 
from  103°  to  110°  F.  according  to  the  condition  of  the  patient  and  the  result 
desired.     It  is  useful  in  relieving  irritation,  the  pain  of  inflammation  in  the 
rectum  or  prostate  and  pain  of  hemorrhoids.     It  also  aids  in  expelling  gas, 
and  helps  to  check  diarrhoea  by  decreasing  rectal  tenesmus.     It  may  be  used 
as    a    preliminary  measure  in  the  treatment    of  dysmenorrhoea.     The    hot 
enema  is  also  used  to  warm  and  stimulate  the  body  in  shock. 

2.  Warm  Enema — En.     The  ordinary  enema  for  cleansing  purposes  should 
be  given  at  a  temperature  of  95°  to  100°  F.     Where  it  has  to  be  repeated  fre- 
quently it  is  better  to  use  tepid  water,  i.  e.,  80°  to  92°  F.,  to  avoid  as  far  as 
possible  the  relaxing  effect  of  warm  water. 

3.  Cold  Enema — C.  En.     In  giving  the  cool  or  cold  enema  the  tempera- 
ture of  the  water  may  vary  from  55°  to  80°  F.     Up  to  about  70°  F.  it  may  be 
regarded  as  cold,  and  from  70°  to  80°  F.  as  cool.     The  cold  enema  is  a  power- 


292  TECHNIQUE  OF  HYDROTHERAPY 

ful  stimulant  to  bowel  movements  and  should  be  more  generally  used  for 
this  purpose  in  place  of  the  warm  enema.  For  this  reason  it  is  useful  in 
overcoming  the  enema  or  cathartic  habits.  If  retained  ten  or  fifteen  min- 
utes or  frequently  repeated  is  useful  in  shrinking  hemorrhoids.  It  may  also 
be  used  in  fever,  but  for  this  purpose  prolonged  rectal  irrigation  is  much 
more  convenient  and  effective. 

GRADUATED  ENEMA 
(GRAD.  E.) 

The  graduated  enema  is  not  a  single  treatment  but  a  series  of  treatments. 
It  is  used  to  overcome  the  enema  or  cathartic  habits.  As  usually  given,  it 
extends  over  a  period  of  ten  to  twelve  days.  It  should  be  preceded  on  two 
or  three  successive  days  by  thorough  coloclysters  of  water  at  90°  to  100°  F. 
to  remove  accumulated  feces. 

The  series  of  enemata  is  begun  with  a  large  amount  of  tepid  water  and 
finished  with  a  small  amount  of  cold  water,  one  enema  being  given  daily. 

1st  day  4J  pints  at  94°  F.  6th  day  2  pints  at  74°  F. 

2nd  "    4        "      "  90°  F.  7th    "    1J    "     "   70°  F. 

3rd    "   3&       "     "  86°  F.  8th    "    1      "     "   66°  F. 

4th   "   3        "     "  82°  F.  9th    "      }     "    "    62°  F. 

5th   "   2J      "     "  78°  F.  10th    "      J     "     "   58°  F. 

The  above  program  is  suggestive  only;  the  variations  in  the  amount  and 
temperature  of  the  water  should  be  made  to  suit  the  needs  of  the  case. 
The  entire  series  with  the  exception  of  the  temperatures  above  80°  F.,  may 
need  to  be  repeated.  Cold  enemata  should  not  be  given  during  the  menses. 

Effects.  After  prolonged  use  of  cathartics,  the  muscular  part  of  the 
intestinal  wall  becomes  relaxed  and  atonic  because  of  overstimulation.  The 
response  to  drug  and  chemical  excitants  is  worn  out  and  it  is  necessary  that 
the  atony  be  overcome  by  some  more  physiologic  means.  The  restorative 
effect  of  cold  upon  muscular  tissue  and  muscular  capacity  has  been  discussed 
in  detail  in  Chapter  XIII.  Repeated  use  of  the  warm  or  hot  enema  also  causes 
relaxation  with  stretching  and  distention  of  the  wall  of  the  rectum  and 
lower  sigmoid  flexure. 

The  contact  with  the  cold  water  introduced  into  the  bowel  is  an  effective 
means  of  combating  this  atony  and  distention.  The  gradual  reduction  in 
the  temperature  makes  it  possible  to  bring  about  a  response  even  after  the 
atony  has  existed  for  some  time.  Both  this  treatment  and  alternate  hot 
and  cold  rectal  irrigation  are  very  efficient  in  the  treatment  of  atonic  con- 
stipation. They  may  be  advantageously  combined  with  the  use  of  slow 
intra-rectal  and  abdominal  sinusoidal  electricity,  abdominal  massage  and 
spinal  nerve  stimulation. 

RECTAL  IRRIGATION 

(Rec.  Irrig.) 

In  giving  rectal  irrigation  a  special  tube  is  used  which  is  provided  with 
an  inlet  and  a  return  flow,  so  that  the  fluid  passes  into  the  rectum  bathing 
the  mucous  membrane,  and  returns  through  the  outlet.  These  are  made  of 
hard  rubber  or  metal.  The  patient  should  be  in  the  dorsal  or  Sims  position. 


EN  EM  AT  A  293 

The  enema  can  should  be  eighteen  inches  to  two  feet  above  the  patient. 
The  outflow  tube  should  be  lengthened  by  attaching  to  it  a  piece  of  rubber 
tubing  so  as  to  carry  the  outflow  into  the  toilet  fixture  or,  if  given  to  a  bed 
patient,  into  a  jar  placed  at  the  side  of  the  bed. 

1.  Hot  Rectal  Irrigation — H.  Rec.  Irrig.     When  the  water  used  is  at  a  tem- 
perature of  102°  to  105°  or  106°  F.,  the  treatment  produces  decided  effects 
in  the  relief  of  pain  and  rectal  tenesmus.      It  may  also  be  used  with  great 
benefit  in  cases  of  chronic  cystitis  with  frequent  and  painful  urination. 

2.  Cold  Rectal  Irrigation — C.  Rec.  Irrig.      Cold  rectal  irrigation  is  a  very 
useful  antipyretic  measure.     For  this  purpose  the  water  should  not  be  very 
cold,  but  from  about  70°  to  80°  F.,  and  the  treatment  continued  about  forty- 
five  minutes  at  a  time. 

Cold  irrigation  is  also  useful  in  stimulating  bowel  movement,  but  for  this 
purpose  it  possesses  no  advantage  over  the  cold  enema. 

3.  Alternate  Hot  and  Cold  Rectal  Irrigation— Alt.  H.  &  C.  Rec.  Irrig.     In 

giving  alternate  hot  and  cold  irrigation  it  is  necessary  to  use  two  enema 
cans  with  tubing  connected  by  a  Y-tube  so  that  the  alternations  may  be  con- 
trolled. The  hot  should  be  allowed  to  run  from  one-half  to  two  minutes 
and  the  cold  from  fifteen  to  thirty  seconds.  From  five  to  twelve  or  more 
complete  changes  may  be  made  in  a  single  treatment.  The  greater  the 
extremes  of  temperature  the  greater  will  be  the  effect.  It  is  possible  to 
use  a  plain  enema  tube,  injecting  but  a  small  amount  and  allowing  the 
water  to  pass  out  through  the  enema  tube  after  each  injection. 

This  treatment  is  a  most  efficient  measure  in  the  relief  of  chronic  inflam- 
mations of  the  pelvic  organs,  especially  of  the  bladder,  prostate,  posterior 
urethra  and  rectum.  For  these  purposes  it  should  be  given  daily  or  three 
or  four  times  a  week.  It  is  also  one  of  the  most  effective  means  of  combat- 
ing chronic  atonic  constipation. 

COLOCLYSTER 

(Ccl.) 

In  a  coloclyster  the  fluid  is  introduced  into  the  colon. 

When  the  coloclyster  is  used  to  produce  thorough  cleansing  of  the  large 
bowel,  four  to  six  pints  of  water  or  saline  solution  at  a  temperature  of  100° 
to  104°  F.,  are  used  for  each  injection.  An  ordinary  enema,  and  if  necessary 
a  soap-suds  enema,  is  first  used  to  cleanse  the  lower  bowel.  Have  the 
patient  take  the  knee-chest  or  right  Sims  position.  Use  an  ordinary  enema 
tube,  but  if  results  are  not  obtained,  it  may  be  necessary  to  use  the  high 
bowel  catheter  (colon  tube).  As  the  water  enters,  rub  along  the  colon  up 
the  left  side,  across  the  abdomen  and  down  on  the  right  side  so  as  to  fill 
well  the  large  bowel.  As  much  water  as  possible  should  be  injected,  but 
this  should  be  done  slowly.  Remove  the  enema  or  colon  tube  and,  as  the 
water  is  expelled,  reverse  the  movements  along  the  colon  to  favor  complete 
emptying.  It  may  be  necessary  to  repeat  the  procedure. 

Effects.  The  coloclyster  is  used  to  produce  a  full  and  complete  evacuation 
of  the  bowels,  and  for  cleansing  the  large  bowel  in  cases  where  an  ordinary 
enema  does  not  produce  the  desired  results.  It  is  also  used  to  remove  fecal 
impaction.  When  some  medicament  or  antiseptic  is  introduced  it  may  be 


294  TECHNIQUE  OF  HYDROTHERAPY 

used  to  disinfect  the  large  intestine  or  destroy  parasites,  as  the  amoeba  coli. 
(See  quinin  also  quassia  enema). 

II.  MEDICATED  ENEMATA 

SALINE  ENEMA 

(Sal.  En.) 

For  whatever  purpose  the  saline  enema  is  used,  it  should  be  preceded  by 
a  thorough  cleansing  enema  unless  the  bowel  has  already  been  cleared  of 
feces. 

1.  Saline  Enema  to  be  Retained  and  Absorbed.  The  absorption  of  saline 
fluid  from  the  rectum  is  useful  in  hemorrhage,  surgical  shock  and  pelvic  and 
abdominal  abscesses  after  drainage  has  been  instituted.  To  be  absorbed 
most  rapidily,  the  sodium  chloride  solution  should  be  isotonic  with  blood 
serum  or  slightly  hypotonic.  A  physiologic  salt  solution  is  so  called  because 
it  is  isotonic  with  blood  serum. 

Intermittent  Proctoclysis.  One-half  pint  of  physiologic  salt  solution  (0.95 
per  cent)  at  a  temperature  of  100°  to  105°  F.,  is  given  slowly  or  by  high 
bowel  catheter.  To  make  this,  use  one  level  teaspoonful  (4.5  grams  or  less) 
of  salt  to  the  pint  of  water.  For  a  hypotonic  solution  (more  rapid  absorp- 
tion) use  a  little  less  salt.  After  this  has  been  absorbed,  another  one-half 
pint  may  be  given.  If  this  amount  is  not  readily  retained,  use  four  or  five 
ounces  only. 

Continuous  Proctoclysis.  Murphy  Method.  J  The  fluid  should  be  adminis- 
tered through  a  fountain  syringe  to  which  is  attached  a  three-eights  inch 
rubber  hose  with  a  hard  rubber  or  glass  vaginal  douche  tip  with  multiple 
openings.  This  tube  should  be  flexed  almost  to  right  angles,  three  inches 
from  its  tip.  A  straight  tube  must  not  be  used,  as  the  tip  produces  pres- 
sure on  the  posterior  wall  of  the  rectum  when  the  patient  is  in  the  Fowler 
position.  The  tube  is  inserted  into  the  rectum  to  the  flexion  angle  and 
secured  in  place  by  adhesive  strips,  binding  it  to  the  side  of  the  thigh  so 
that  it  can  not  come  out;  the  rubber  tubing  is  passed  under  the  bedding  to 
the  head  or  foot  of  the  bed,  to  which  the  fountain  is  attached. 

Two  or  three  inches  from  the  fountain  syringe  interpose  a  Y-tube  and  to 
the  upper  limb  attach  a  piece  of  rubber  hose  of  the  same  size  as  the  outlet  tube. 
Fasten  the  free  end  of  this  to  the  top  of  the  fountain  syringe  so  that  what 
returns  through  it  will  fall  into  the  container.  When  flatus  is  voided,  the 
gas  passes  more  readily  through  the  upper  tube  than  directly  into  the  foun- 
tain syringe.  This  reduces  the  pressure  at  such  times  and  so  aids  in  pre- 
venting expulsion  of  the  fluid  onto  the  linen. 

The  fountain  syringe  should  be  suspended  from  six  to  fourteen  inches 
above  the  level  of  the  buttocks  and  raised  or  lowered  to  just  overbalance 
hydrostatically  the  intra-abdominal  pressure,  i.  e.,  it  must  be  just  high 
enough  to  require  from  forty  to  sixty  minutes  for  one  and  one-half  pints  to 
flow  in,  the  usual  quantity  given  every  two  hours.  The  flow  must  be  con- 
trolled by  gravity  alone,  and  never  by  a  forceps  or  constriction  on  the  tube,  so 
that  when  the  patient  endeavors  to  void  flatus  or  strain,  the  fluid  can  rapidly 
flow  back  into  the  can,  otherwise  it  will  be  discharged  in  the  bed.  It  is  this 

1     Slightly  modified  from  the  original  description  by  J.  B.  Murphy. 


EN  EM  AT  A  295 

ease  of  flow  to  and  from  the  bowel  that  insures  against  over-distension  and 
expulsion  onto  the  linen.  The  fountain  had  better  be  a  glass  or  graded  can, 
so  that  the  flow  can  be  estimated.  The  temperature  of  the  water  in  the 
fountain  can  be  maintained  at  100°  by  encasement  in  hot  water  bags.  The 
fountain  is  refilled  every  two  hours  with  one  and  one-half  to  two  pints  of 
solution.  Instead  of  the  usual  solution,  a  teaspoonful  of  calcium  chloride 
may  be  added  to  the  pint  of  saline  solution.  The  tube  should  not  be  removed 
from  the  rectum  after  each  emptying  of  the  syringe  but  may  be  left  in  place 
for  two  or  three  days  if  necessary.  For  the  effects  of  enteroclysis,  see 
Chapter  IX. 

2.  Saline  Enema  to  Cause  Exosmosis,  acting  like  a  saline  cathartic.  Used 
to  produce  exosmosis,  the  enema  is  designed  for  thorough  cleansing  of  the 
mucous  membrane  and  is  of  inestimable  value  in  chronic  mucous  colitis. 

To  produce  exosmosis,  i.  e.,  draw  water  from  the  tissues  into  the  bowel, 
the  solution  must  be  hypertonic,  i.  e.,  of  greater  concentration  than  blood 
serum.  Three  pints  of  warm  or  hot  water  are  used,  containing  about  two 
teaspoonfuls  of  salt  or  one-fourth  teaspoonful  of  Epsom  salts  added  to  a  phy- 
siologic salt  solution.  The  enema  should  be  intoduced  into  the  colon  by  high 
bowel  catheter  or  its  flow  into  the  colon  aided  by  the  knee-chest  position. 
Let  it  be  retained  fifteen  to  twenty  minutes  or  longer.  If  retained  much 
over  half  an  hour,  some  fluid  will  be  absorbed.  The  treatment  should  always 
be  preceded  by  an  ordinary  enema  to  remove  feces. 

SOAP-SUDS  ENEMA 

(S.  S.  En.) 

Prepare  two  or  three  pints  of  warm  soap-suds  solution,  made  by  scraping 
castile  or  yellow  laundry  soap  and  mixing  thoroughly  in  water  at  about  100C 
F.  Follow  by  a  plain  enema  to  remove  the  soap  suds. 

Effects.  The  soap-suds  enema  facilitates  evacuation  of  the  bowels  and 
should  be  used  where  the  plain  enema  fails  to  produce  results. 

OIL  ENEMA 

(Oil  En.) 

In  administering  the  oil  enema,  use  the  colon  tube  with  a  small  enema  can 
giving  one  and  one-half  to  three  or  four  ounces  of  warmed  cotton  seed  or 
other  vegetable  oil.  It  should  be  retained  from  two  to  ten  or  twelve  hours 
or  over  night.  Pass  it  the  next  morning  and  follow  by  soap-suds  and  plain 
enemata. 

Effects.  The  oil  enema  is  used  to  remove  hardened  or  impacted  feces. 
It  has  a  soothing,  relaxing  effect,  and  is  therefore  used  to  overcome  spastic 
constipation,  as  of  chronic  lead  poisoning. 

When  given  two  or  three  days  after  an  operation  for  hemorrhoids,  it 
softens  and  loosens  the  clot  so  that  it  passes  without  causing  pain  or  start- 
ing fresh  bleeding. 

HONEY  OR  MOLASSES  ENEMA 

Give  one-half  to  one  pint  of  warmed  molasses  or  the  same  amount  of  two 
parts  soap-suds  and  one  of  molasses  by  high  bowel  catheter.  Follow  by 
plain  enema. 


296  TECHNIQUE  OF  HYDROTHERAPY 

Effects.  The  honey  or  molasses  enema  has  a  purging  effect  similar  to  that 
of  the  hypertonic  saline  enema.  It  aids  in  removing  the  mucous  casts  and 
mucus  accumulations  of  chronic  colitis. 

ASAFOETIDA  ENEMA 

To  one  pint  of  warm  water  add  four  ounces  of  an  emulsion  of  asafcetida, 
prepared  by  agitating  one-half  dram  of  asafoetida  powder  in  four  ounces  of 
water;  or  add  one  ounce  of  tincture  of  asafoetida  to  a  pint  of  warm  water. 
Give  as  an  ordinary  enema.  It  is  used  to  expel  flatus. 

TURPENTINE  ENEMA 

To  a  pint  of  soap-suds  solution  add  ten  to  twenty  drops  of  oil  of  turpentine. 
Follow  by  a  plain  enema.  The  turpentine  enema  is  given  in  the  same  way 
and  for  the  same  purpose  as  the  asafoetida  enema.  Its  action  is  somewhat 
more  vigorous.  It  should  be  used  where  there  is  kidney  irritation  or  Bright's 

disease. 

GLYCERINE  AND  EPSOM  SALTS  ENEMA 

The  glycerine  and  Epsom  salts  enema  is  a  vigorous  purgative.  It  is  used 
in  cases  of  fecal  impaction  and  obstinate  constipation  (obstipation). 

Just  before  using,  prepare  a  mixture  consisting  of  two  ounces  of  mag- 
nesium sulphate,  two  ounces  of  glycerine,  and  sufficient  warm  water  (about 
two  ounces)  to  make  it  pass  readily  through  the  colon  tube. 

First,  cleanse  the  lower  bowel  from  feces  and  then  inject  the  mixture  by 
high  bowel  catheter,  using  gentle  pressure  with  a  rubber  bulb  if  necessary. 
Considerable  patience  and  persistence  may  be  necessary  to  secure  results. 
In  supposed  cases  of  fecal  impaction,  great  care  should  be  exercised  in  diag- 
nosis that  a  case  of  intussusception  is  not  treated  in  this  way. 

STARCH  ENEMA 

The  warm  starch  enema  is  given  to  relieve  irritation  and  check  diarrhcea. 
Make  a  thin  paste  of  starch  in  one  or  two  ounces  of  cold  water.  Add  hot 
water  enough  to  make  from  four  ounces  to  one  pint  of  solution.  Inject 
slowly  after  giving  a  hot  cleansing  enema.  The  sedative  effect  may  be 
made  greater  and  pain  relieved  by  adding  five  to  twenty  drops  of  laudanum. 

ASTRINGENT  ENEMA 

An  astringent  mixture  is  useful  in  controlling  or  checking  diarrhoea  and 
dysentery.  Either  of  the  following  formulas  may  be  used: — 

a.  A  heaping  tablespoonful  of  tannin  to  one  pint  of  water  at  100°  F. 

b.  An  ounce  of  glycero  of  tannin  to  one  pint  of  water  at  100°  F. 

QUASSIA  ENEMA 

The  quassia  enema  is  used  to  destroy  and  remove  thread  or  pinworms 
(oxyuris  vermicularis).  Prepare  an  affusion  of  quassia  by  pouring  over  one 
and  one-half  drams  of  finely  rasped  quassia  wood,  twenty  ounces  of  warm 
water,  let  it  stand  twenty  to  thirty  minutes  and  strain.  Use  a  plain  cleans- 
ing enema  first;  then  cleanse  the  colon  thoroughly  with  warm  water  contain- 
ing a  teaspoonful  of  borax  to  the  pint.  Now  inject  into  the  colon  (coloclys- 


VAGINAL  IRRIGATION  297 

ter)  a  half  to  a  pint  of  the  infussion  of  quassia;  retain  as  long  as  possible. 
A  1  to  10,000  bichloride  solution  may  be  used  instead  of  the  quassia.  It 
should  not  be  retained  very  long. 

QUININ  ENEMA 

The  quinin  enema  is  used  for  amoebic  dysentery.  After  thorough  cleans- 
ing of  the  bowel  by  low  enema  and  colon  flushing,  inject  by  high  bowel 
catheter,  from  two  to  four  or  more  pints  of  a  warmed  solution  of  quinin,  1 
to  1000  or  2500.  Large  and  frequently  repeated  coloclysters  of  cold  water 
may  be  used.  Quinin  kills  the  amoebae.  Cold  water  paralyzes  them  for  a 
time.  Position  of  patient — hips  elevated. 

In  very  obstinate  and  long  standing  cases  of  amcebic  dysentery,  colonic 
flushings  with  cold  water  or  the  quinin  solutions  are  sometimes  carried  out 
by  means  of  appendicostomy. 


VAGINAL  DOUCHES  OR  IRRIGATION 

A  vaginal  douche  consists  in  the  flushing  or  irrigating  of  the  vaginal  cavity 
by  a  fluid. 

General  Directions:— 

a.  Articles  Necessary  in  the  Treatment  Room: — douche  table,  fountain 
syringe  or  douche  can  with  a  capacity  of  one  to  two  gallons,  five  or  six  feet 
of  rubber  tubing,  douche  tube  of  glass  or  hard  rubber,  lubricant,  disinfec- 
tant, sheets  and  napkins.       Additional  need  in  private  room, — standard  or 
hooks  for  douche  can,  a  douche  pan,  slop  jar,  and  rubber  sheeting  or  papers. 

b.  Procedure.     Preparation  of  the  douche.     Fill  the  can  with  from  two 
to  four  quarts  of  water  at   the  prescribed  temperature  and  place  it  from 
three  to  four  feet  above  the  patient.     Always  use  a  thermometer  in  prepar- 
ing vaginal  douches. 

Preparation  of  patient.  If  the  clothing  is  not  removed  protect  thoroughly. 
Always  cover  the  patient  with  a  sheet.  Lubricate  the  tube  with  vaseline  or 
soap.  Release  the  cut-off  and  allow  the  water  to  run  a  few  seconds.  Instruct 
the  patient  to  insert  the  tube  unless  helpless. 

Position  of  patient.  Dorsal  position  with  hips  raised  and  thighs  and  legs 
flexed. 

I.  PLAIN  VAGINAL  IRRIGATION 
VAGINAL  IRRIGATION  FOR  ORDINARY  USE 

1.  Hot  Vaginal  Irrigation — V.  I.      This  is  used  for  cleansing    purposes. 
Two  to  four  quarts  of  water  are  employed  at  a  temperature  of  105°  to  115°  F. 
Finish  with  a  pint  of  water  at  70°  F. 

In  the  treatment  of  pelvic  inflammations,  the  hot  vaginal  douche  is  usually 
given  as  a  preliminary  to  the  use  of  the  sitz  bath,  hot  half-bath  or  the  hip 
and  leg  pack. 

2.  Very  Hot  Vaginal  Irrigation — H.  V.  I.      The  very  hot  vaginal  irriga- 


298  TECHNIQUE  OF  HYDROTHERAPY 

tion  is  designed  for  the  relief  of  pain  or  to  check  hemorrhage.  Two  to  four 
quarts  of  water  are  used  at  a  temperature  of  110°  to  125°  F. 

3.  Alternate  Hot  and  Cold  Vaginal  Irrigation— H.  &  C.  V.  I.  Alternate 
hot  and  cold  vaginal  irrigation  is  given  for  tonic  and  stimulating  effects.  It 
is  also  useful  in  chronic  pelvic  inflammations.  Use  two  cans  with  a  Y-tube 
connection.  Put  four  quarts  of  water  in  one  can  at  a  temperature  of  110°  to 
120°  F.,  and  two  quarts  of  water  in  the  other  at  a  temperature  of  70°  F. 

Give  the  hot  fifteen  to  twenty  seconds  and  the  cold  five  to  ten  seconds.  Con- 
tinue the  alternations  for  five  to  ten  minutes,  beginning  with  hot  and  finish- 
ing with  cold. 

VAGINAL  IRRIGATION  DURING  PREGNANCY 

During  pregnancy  certain  precautions  must  be  observed.  The  pressure 
of  the  water  must  not  be  too  great,  i.  e.,  the  douche  can  must  not  be  placed 
too  high.  Very  cold  water  or  extremely  hot  water  should  not  be  used.  It 
is  positively  necessary  that  the  openings  in  the  bulb  of  the  douche  tube  be 
lateral  and  not  directly  on  the  end.  During  pregnancy  vaginal  irrigation  is 
given  chiefly  for  cleansing,  for  the  treatment  of  leucorrhrea  and  for  the  relief 
of  irritation.  Use  two  to  four  quarts  of  water  at  a  temperature  of  98°  to 
105°  F.  Hang  the  douche  can  twelve  to  eighteen  inches  above  the  hips. 

II.  DISINFECTANT  AND  MEDICATED  DOUCHES 

SOAP-SUDS  VAGINAL  IRRIGATION 

(S.  S.  V.  I.) 

Use  two  quarts  of  soap-suds  solution  prepared  from  laundry  soap  or  green 
soap  solution,  at  a  temperature  of  105°  to  110°  F.  Wrap  the  tube  in  cheese 
cloth  and  swab  the  vagina  carefully,  but  thoroughly,  while  the  water  is  flow- 
ing. Follow  by  plain  vaginal  irrigation,  then  give  a  permanganate  or 
bichloride  douche. 

The  soap-suds  vaginal  irrigation  is  used  to  prepare  patients  for  surgical 
operations  or  for  special  cleansing  and  disinfectant  purposes. 

PERMANGANATE  OF  POTASSIUM  VAGINAL  IRRIGATION 

(P.  V.  I.) 

To  one  quart  of  water  add  two  drams  (two  teaspoonfuls)  of  a  saturated 
solution  of  potassium  permanganate — (1  to  2000).  Temperature — 110°  to 
120°  F.  Precede  by  a  plain  vaginal  irrigation.  Oxalic  acid  (sat.  sol.)  will 
remove  the  stain. 

The  permanganate  douche  is  used  as  a  deoderant  and  disinfectant  in  the 
treatment  of  vaginal  inflammations,  leucorrhrea,  etc.,  also  as  a  disinfectant 
preparatory  to  operation. 

BICHLORIDE  OF  MERCURY  VAGINAL  IRRIGATION 

(Bichlor.  V.  I.) 

Use  one  dram  (a  teaspoonful)  of  a  saturated  solution  of  bichloride  of  mer- 
cury to  one  or  two  quarts  of  water — (1-4000  or  8000) .  Temperature — 110°  to 
115  F. 

Always  precede  by  plain  vaginal  irrigation,  so  as  to  remove  all  mucus  and 


VA GINAL  IRRIGA  TION  299 

other   secretions.       If  this  is  not  done  the  disinfectant  properties  of   the 
bichloride  are  lessened  by  its  combination  with  albuminous  substances. 

CARBOLIC  ACID  VAGINAL  IRRIGATION 
(Carb.  V.  I.) 

Use  one-half  ounce  of  a  five  per  cent  solution  to  one  quart  of  water. 
Temperature — 110°  to  115°  F.  Be  sure  that  the  solution  is  thoroughly  mixed 
with  the  water,  otherwise  a  carbolic  acid  burn  may  result.  Always  have 
alcohol  at  hand  in  giving  this  douche. 

CREOLIN    OR  LYSOL  VAGINAL  IRRIGATION 

Use  a  one  or  two  per  cent  solution  of  either  lysol  or  creolin  in  water  at  a 
temperature  of  110°  to  12(>°  F.  These  disinfectants  are  much  used  after  con- 
finement where  puerperal  infection  has  occurred  or  in  case  of  a  suspicious 
odor  to  the  lochia. 

ACETIC  ACID  OR  VINEGAR  VAGINAL  IRRIGATION 

The  acetic  acid  douche  is  used  to  check  hemorrhage.  Use  one  quart  of 
boiled  vinegar  to  one  quart  of  water,  or  one  ounce  of  glacial  acetic  acid  to 
one  quart  of  water.  Temperature — 115°  to  120°  F. 

ALUM  VAGINAL  IRRIGATION 
(Alum  V.  I.) 

The  alum  douche  is  also  used  to  check  hemorrhage  or  prolonged  menses. 
Add  one  pint  of  a  saturate  solution  of  alum  to  one  pint  of  water.  In 
extreme  cases  the  sat.  sol.  may  be  used.  Temperature — 115°  to  120°  F. 
Precede  by  plain  hot  vaginal  irrigation. 


INDEX 


Abdominal  bandage,  250 
Abscess,  134,  191 

alveolar,  137,  280 
Absorption  by 

blood  vessels,  55 

body  membranes,  52 

lymphatics,  55 

skin,  30 

Acapnia,  230,  233 
Acetanilid,  in  fevers,  101 
Acetic  acid  vaginal  irrigation,  299 
Aconite,  in  fevers,  100 
Active  hyperemia,  25,  56,  131,  133 
Affusions,  290 

in  typhoid,  111 
Alcohol  in 

fevers,  100 

pneumonia,  144 

surgical  shock,  234 
Alcohol  rub,  257 
Alkaline  bath,  269 

sponge,  257 

Alum  vaginal  irrigation,  299 
Amblyopia,  toxic,  135 
Amenorrhoea,  289 
Ammonia,  influence  of  cold  on,  67 

in  uremia,  216 

Amyl  nitrite,  in  surgical  shock,  234 
Analgesic  effects,  182,  191 
Anemia,  159 
Anesthesia,  relation  to  shock,  229 

effect  on  phagocytosis,  236 
Antagonism,  law  of,  46 
Antiphlogistic  effects,  127 
Antipyresis,  principles  of,  97 
Antipyretic  effects,  96 
Antipyretics,  medicinal,  100 
Aritipyrin,  in  fevers,  101 
Apoplexy,  225 
Appendicitis,  127,  151,  280 
Arrhythmia,  in  heart  disease,  176 
Arteriosclerosis,    relation    of  elastic 

tissue  to,  18 
Articular  rheumatism,  acute,  148 

chronic,  166 
Asafoetida  enema,  296 
Asthma,  199 
Astringent  enema,  296 
Ataxia,  locomotor,  188,  289 

Balneology,  8 
Baths,  261 
air,  superheated,  272 


alkaline,  269 

Brand,  103,  109,  266 

cold,  266 
rationale  of,  112 

diagnostic,  112 

effervescent,  see  Nauheim 

electric  light,  273 

electric  tub,  267 

foot,  262 

full  immersion,  265 

graduated,  110,  267 

graduated  shower,  286 

half,  265 

hand  and  arm,  262 

hydro-electric,  267 

leg,  263 

medicated,  269 

Nauheim,  26,  269 
in  heart  disease,  173 

partial  immersion,  262 

rain,  see  sprays 

Russian,  271 

saline,  269 

shallow,  158,  267 

shower,  see  sprays 

sitz,  264 

sun,  in  anemia,  161 
in  neurasthenia,  164 

tub,  265 

Turkish,  272 

vapor,  272 

Bier's  hyperemia,  133 
Biliary,  colic,  195 

inflammations,  151 
Biliousness,  219 
Blanket  packs,  276 
Blood,  effects  on  composition  of,  59 

reaction  of,  62 

viscosity  of,  62 
Blood  poisoning,  138 
Blood  pressure,  23,  45,  52 

effects  of  heart  beat  on,  52 

effects  of  volume  of  fluid  on,  52,  55 

effects  of  vascular  calibre  and  ac- 
tion on,  56 

in  Bright's  disease,  210 

laws  of  effects  on,  57 
Blood  vessels,  18 

action  of,  25,  56,  171,  231 

calibre  of,  56,  231 

capillary  loops  in  skin,  18 

effects  of  heat  and  cold  on,  25 

pumping  action  of,  57,  171,  231 


INDEX 


301 


in  malaria,  120 

reaction  in,  25 
Boils,  138 
Bright's  disease,  210 

acute,  213 

chronic,  214 
Bronchitis,  acute,  198 

chronic,   199 
Bronchopneumonia,  145 

in  measles,  122 
Bruises,  195 
Burns,  195 

Caffein,  see  coffee 
Calorie,  5 

Carbolic  acid  vaginal  irrigation,  299 
Carbon  dioxide,  effects  on  blood  ves- 
sels, 26 

influenced  by  heat  and  cold,  74,  114 

in  fevers,  114 

in  Nauheim  bath,  269 

in  surgical  shock,  see  acapnia 

respired  by  skin,  31 
Carbancles,  138 
Cardiac  changes  in  shock,  231 
Catarrhal  jaundice,  151 
Cathartics,    in    edema  of  nephritis, 

214 

Cellulitis,  pelvic,  152 
Centripetal  friction,  258 
Cerebral  congestion,  128,  168 
Charcoal  poultice,  252 
Chest  packs,  249 
Chlorides,  effect  of  cold  on,  70 
Cholangitis,    151 
Cholecystitis,  151 
Chorea,  186,  289 
Circulation,  33 

balance  between  reflex  and  hydro- 
static effects,  50 

blood  pressure,  52,  see  also  blood 
pressure 

composition  of  blood,  59 

hydrostatic  effects  on,  44 

in  inflammations,  130 

in  pneumonia,  139 

in  surgical  shock,  230 

in  typhoid  fever,  112 

quantity  of  fluid  in,  26 

effects  on  blood  pressure,  52 

reflex  effects  on,  33 
Clark's  column,  3<%  37 
Clay  and  glycerine  poultice,  252 
Coal  tar  products,  in  fever,  101 
Coffee,  a  cause  of  fever,  96 

effects  on  purins,  217 
Coil,  cold  water,  248 
in  typhoid,  111 

hot  water,  246 

Leiter,  248 
Cold 'air,  in  pneumonia,  140 


Cold,  effects  on 

antibodies,  63 

ammonia,  67 

blood  pressure,  22,  45,  57 

blood  vessels,  22,  44 

carbon  dioxide  elimination,  74 

carbonaceous  metabolism,  73 

chlorides,  70 

composition  of  blood,  59 

extractives,  69 

fever,  103 

heat  elimination,  85,  87 

heat  production,  85,  86 

muscular  capacity,  76 

nervous  system  in  typhoid,  112 

nitrogenous  metabolism,  64 

oxygen  absorption,  74 

perspiration,    29 

phosphoric  acid,  69 

purin,  67 

red  cells,  59 

skin  muscles,  17 

sulphates,  70 

sweat  glands,  29 

toxin  elimination  in  typhoid,  113 

urea,  67 

uric  acid,  67 

white  cells,  59 
Cold,  hydrostatic  effects  of,  44 

intrinsic  effects  of,  10 

local  applications  of,  24u 

reaction  to,  11 

reflex  effects  of,  41 
Cold-blooded  animals,  9 
Cold  friction,  effects  on  vasomotors, 
25 

in  fever,  113 

in  heart  disease,  172 

in  shock,  232 
Cold  plunge,  158 
Cold  treatments,  see  distinctive  word 

in  each 
Colds,  198 
Colic,  194 

biliary,  195 

intestinal,  195 

renal,  195 

Colitis,  mucous,  153 
Collapse,  228 
Coloclyster,  293 
Compresses,  243,  244,  246,  248 

cold  in  typhoid,  111 

heating/ 248 

hot  gauze,  243 

joint,  251 

medicated,  252 

revulsive,  244 

throat,  251 
Conjunctivitis,  135 
Convection,  heat  loss  by,  82 
Coryza,  acute,  198 


302 


INDEX 


Cough,  198 

in  pneumonia,  143 
Cravat,   ice,  247 
Creolin  vaginal  irrigation,  299 
Crile,  investigations  of,  228,  233 
Croup,  199 
Cystitis,  154 

Dachryocystitis,  135 
Depletion,  127 
Depressant  effects,  13 
Derivation,  45,  133 

areas  for,  47 

by  hot  alone,  128 

definition  of,  127 
Dermatomes  of  Head,  35 
Dermographism,  16 
Diabetes,  167 
Dialysis,  8 

Diaphoretic  effects,  201 
Diaphoretics,  medicinal,  101,  214 
Diet,  in  Bright's  disease,  210 

in  diabetes,  167 

in  uremia  and  eclampsia,  217 

meat,  effect  on  liver,  216 

purin-free  in  gout,  207 

vegetable  in  gout,  207 
Digitalis,  in  fevers,  113 

in  surgical  shock,  234 
Diuresis,  effects  of 

cold  bath  on,  114 

refrigerants  on,  102 

sweating  on,  201,  205 
Diuretic  effects,  205 
Douches,  285,  287 

cold  as  a  tonic,  158 

vaginal,  see  vaginal  irrigation 
Dover's  powder,  in  fever,  101 
Dripping  sheet  rub,  158 
Duodenal  ulcer,  192 
Dysmenorrhoea,    194 
Dyspepsia,  165,  219 

Eclampsia,  215 

acute,  217 
Edema,  absorption  of,  55 

complicating  heart  disease,  175 

in  Bright's  disease,  211 

of  lungs  in  heart  disease,  176 
Effects,  analgesic,  182 

antiphlogistic,  127 

antipyretic,  96 

depressant,  13,  40 

derivative,  45 

diaphoretic,   201 

diuretic,  64,  205 

emmenagogic,  178 

excitant,  177 

expectorant,  197 

hemostatic,  224 

hydrostatic,  44 


intrinsic,  10 

metabolic,  64,  73,  202,  205 

oxytocic,  78 

peptogenic,  219 

primary,  12 

principles  of,  9 

reactionary,  12 

reflex,  33 
of  cold,  41 
of  heat,  43 

retrostatic,  46 

secondary,  12 

sedative,  40,  180 

stimulant,  40,  156,  177 

tonic,  13,  156,  177 

vascular,  25 

Effervescent  bath,  see  Nauheim  bath 
Eggs  in  anemia,  160 
Elastic  tissue  of  skin,  17 
Electric  light  bath,  273 
Electric  tub  baths,  267 
Electro-thermal  baths,  267 

packs,  280 

Emmenagogic  effects,  178 
Endocarditis,  in  scarlet  fever,  124 

in  rheumatic  fever,  149 
Endometritis,  152 
Enemata,  290 

asafcetida,  296 

astringent,  296 

cold,  in  typhoid,  111 

glycerine  and  Epsom  salts,  296 

graduated,  292 

medicated,  294 

molasses,  295 

oil,  295 

plain  water,  291 

quassia,  296 

quinin,  297 

saline,  294.  295 

soap-suds,  295 

starch,  296 
Epistaxis,  224 
Erectores  pilorum,  17 
Ergograph  experiments,  76,  164 
Erysipelas,  136 
Ether,  method  of  giving,  227 
Exercise,  effect  on  lymph  movement, 
27 

effect  on  reaction,  14 

in  diabetes,  168 
Expectorant  effects,  197 
Evaporation,  effect  on  reaction,  15 

heat  Ipss  by,  83 

Faradic  tub  bath,  268 
Fever,  96 

causes  of,  97 

circulatory  failure  in,  98 

hydrotherapy  in,  102 

manifestations  of,  97 


INDEX 


mechanism  of  production,  105 

medicinal  antipyretics  in,  100 

rheumatic,  148 

scarlet,  123 

treatment  of,  108 

typhoid,  108 

variations  that  produce,  106 
Flexner's  serum,  150 
Fluxion,  128,  133 

definition  of,  127 
Fomentations,  241 
Foot  baths,  262 
Fractures,  196 
Friction,  258 

cold  mitten,  157,  253 

centripetal,  258 

dry,  261 

tonic,  252    ' 
Frog,  a  cold-blooded  animal,  10,  81 

Galvanic  tub  bath,  268 

Gastrectasia,  219,  222 

Gastric  lavage,  in  dyspepsia,  222 

in  surgery,  238 
Gastric  secretion,  effect  of  cold  on, 

220 

Gastric  ulcer,  192 
Gastroptosis,  219,  222 
Glands,  sebaceous,  30 

sweat,  28 
Glaucoma,  135 
Glycerine    and    Epsom  salts   enema, 

296 
Glycerine   and   white   clay  poultice, 

252 

Goitre,  189 
Gout,  206 
Grippe,  124 
Gymnastics,  resistant,  173 

Half -bath,  265 

Heart,  beat,  effect  on  blood  pressure, 

52 

force  of  in  infections,  99 
disease,  valvular,  169 

fatty,  176 

failure  in  typhoid,  113 
innervation  of,  36 
peripheral,  22,  26,  171 
reflex  arc  to,  37 

Heat,  loss,  82,  84,  86,  87,  103,  105 
mechanism,  81 

production,  81,  84,  85,  86,  103,  105 
regulation,  88 
Heat,  absorption  and  communication 

of,  3 

effects  on, 

blood  pressure,  45,  57 
carbon  dioxide,  74 
carbonaceous  metabolism,  74 
composition  of  blood,  59 


fever,  103 
metabolism,  71,  74 
muscles  of  skin,  18 
muscular  capacity,  79 
nitrogenous  metabolism,  71 
oxygen,  74 
red  cells,  59 
respiration,  73 
sweat  glands,  28 
white  cells,  59 

hydrostatic  effects  of,  44 

intensity  of,  4 

latent,  6 

local  applications  of,  241 

physics  of,  3 

quantity  of,  heat  units,  5 

radiant,  246 

reaction  to,  13 

specific,  5 
Heat  stroke,  168 
Hemorrhage,  gastric,  224 

in  typhoid,  115 

pulmonary,  224 

relation  to  shock,  229 

uterine,  225 
Hemorrhoids,  192 
Hemostatic  effects,  224 
Henderson,  work  on  acapnia,  228 

work  on  veno-pressure,  231 
Hilton's  law,  35 
Hip  and  leg  pack,  279 
Hip  pack,  see  pelvic  pack 
Homeothermic  animals,  10 

reaction  of,  10 
Hot  and  cold  treatments, 

douche,  289 

foot  bath,  263 

leg  bath,  264 

pelvic  pack,  279 

rectal  irrigation,  293 

shower,  286 

spray,  see  shower 

to  head,  244,  245 

to  spine,  244 

trunk  pack,  278 
Hot  water  bottles,  245 
Hydrogogue  action  of  hypertonic  solu- 
tions, 54 
Hydrostatic  effects,  44 

balance    between — and   reflex    ef- 
fects, 50 

secondary,  46 
Hyperchlorhydria,  222 
Hyperemia,  active,  25,  56,  129,  130 

arterial,  see  active 

Bier's,  133 

collateral,  127 

passive,  25,  56,  130 
Hyperthyroidism,  see  goitre 
Hypertonic  solutions,  54,  259 
Hypochlorhydria,  219,  289 


304- 


INDEX 


Hypodermoclysis,  56 
Hysteria,  165 

Ice  bag,  248 

effect  of  over  heart,  37 

in  heart  disease,  171 

in  goitre,  190 

with  hot  packs,  279 
Ice  cap,  see  ice  bag 
Ice  cravat,  247 
Ice  pack,  247 

in  pneumonia,  142 
Ice  rub,  255 

in  typhoid,  111 
Icterus,  203 
Inebriety,  166 
Infections,  post  anesthetic,  236 

see    also    fevers,     inflammations, 

puerperal, 
Inflammations,  127 

biliary,  157 

deep-seated,  191 

defined,  130 

of  eye,  135 

pelvic,  152 

principles  of  treatment,  131 

pathogenesis  of,  130 

superficial,  192 

treatment  of,  135 
Influenza,  124 
Intestinal  colic,  195 

stimulants,  178 
Insomnia,  166,  184 
Intrinsic  effects  of  cold,  10 

of  heat,  11 

time  factor  in,  12 
Iritis,  135 
Iron,  in  anemia,  159 

organic,  160 
Isotonic  solutions,  54 
Ivy,  poisoning  by,  139 

Jaundice,  see  icterus 

catarrhal,  151 
Joint  compress,  251 

Keratitis,  135 

Kidneys  in  typhoid,  113,  115 

Latent  heat,  6 

Law,  Berthollet's,  208 

Dastre-Morat,  47 

Hilton's,  35 

Muller's,  57 

of  antagonism,  46 

of  balance  between  reflex  and  hy- 
drostatic effects,  50 
Leg  bath,  263 

pack,  279 
Leucocytes,  effects  of  alcohol  on,  100 

coal  tar  products  on,  101 


cold  on,  59,  113 

heat  on,  59,  119 

quinin  on,  101,  119 

in  fevers,  98,  102 

in  inflammations,  130 

in  malaria,  119 
Leucocytosis,  from  cold,  59 

in  malaria,  119 

Leucomaines,  a  cause  of  fever,  96 
Leucopenia,  in  malaria,  119 

in  typhoid,  113 
Light,  9 

Lithium  in  gout,  207,  209 
Liver,  congestion  of,  175 

effects  of  meat  diet  on,  216 
Locomotor  ataxia,  188,  289 
Lumbago,  289,  see  also  rheumatism 
Lymphatics,  19 

absorption  by,  19 

effects  of  stimulation  on,  27 

lymphatic  hearts,  20 

movements  of,  20 

quantity  of  fluid,  26 

valves  of,  19,  20 
Lysol  vaginal  irrigation,  299 

Malaria,  116 

Massage,  effects  on  blood  cells,  62 

effects  on  lymphatics,  27 

in  anemia,  161 

in  diabetes,  168 

in  heart  disease,  172 

in  rheumatism,  210 
Mastoiditis,  128,  136,  280 
Measles,  121 

Meat  diet,  effect  on  liver,  216 
Mechanical  stimuli,  7 

effects,  44 

on  blood  pressure,  57 
on  carbon  dioxide  and  oxygen,  75 
on  muscular  capacity,  79 

vibration,  in  heart  disease,  172 
Medicinal  antipyretics,  100 
Meningitis,  127,  150,  280 
Menstruation  in  typhoid,  115 
Menthol  rub,  257 
Mercury,  specific  heat  of,  5 

bichloride  vaginal  irrigation,  298 
Metabolism,  carbonaceous,  73 

nitrogenous,  64 
Mineral  waters,  8 

absorption  of,  31 

in  rheumatism,  208 
Mitten  friction,  see  friction 
Morphin,  effect  on  phagocytes,  237 
Mortality,  in  typhoid,  115 
Mucous  colitis,  153 
Muscular  tissue  of  skin,  17 

capacity,  76 
Myelitis,  187 
Myocarditis,  148 


INDEX 


305 


diphtheritic,  99 
Nauheim  bath,  26,  269 

in  heart  disease,  173 
Naumann,  experiments  of,  33 
Nephritis,  210 

acute,  213 

chronic,  214 

in  scarlet  fever,  124 

in  typhoid,  115 

sweat  glands  in,  29 
Nerves,  of  skin,  32 

secretory,  40 

temperature,  32 

vasomotor,  distribution  of,  18,  20 

visceral,  40 

Nervous  system,  after  cold  bath,  112 
Neuralgia,  128,  192 

inflammatory,  193 

toxic,  193 
Neurasthenia,  161 

splanchnic,  164 
Neutral  bath,  266 

douche,  288 

electric,  tub  bath,  268 

pack,  282 

shower,  286 

sitz  bath,  264 

temperature,  16 
Nitrogen  economy,  65 
Nitrogenous  metabolism,  64 
Nitroglycerin,  in  surgical  shock,  234 

Obesity,  202 

with  fatty  heart,  176 

rheumatism  with,  208 
Oertel  method,  174 
Oil  enema,  295 

rub,  260 
Ophthalmia,  135 
Osmosis,  8,  54 
Osteomyelitis,  128,  191 
Otitis  media,  136 
Ovaritis,  152 
Oxygen,  effects  of  heat  and  cold  on, 

74,  114 
Oxytocic  effects,  178 

Packs,  276 
blanket,  276 
chest,  249,  250 
electro-thermal,  280 
evaporating,  281 
half-pack,  283 
heating,  282,  see  also  compresses 

pelvic,  284 

trunk,  283 
hip  and  leg,  279 
hot  and  cold  pelvic,  279 
hot  and  heating  trunk,  284 
hot  pelvic,  278 
hot  trunk,  278 


hot,  with  ice  bags,  279 
ice,  247 

leg,  279 

neutral,  282 

sweating,  283 

wet  sheet,  281 

in  typhoid,  110 
Pail  pour,  158,  290 
Pain,  relief  of,  182,  191 

in  pneumonia,  142 
Palpitation,  in  heart  disease,  176 
Pancreatitis,  subacute,  151 
Paraesthesias,  relief  of,  184 
Paralysis  agitans,  187 

spastic  spinal,  187,  289 
Passive  hyperemia,  25,  56,  130,  133 
Pathpgenesis,  of  fever,  96,  105 

of  inflammation,  130 
Pelvic  cellulitis,  152 

inflammations,  152 

pack,  heating,  284 
hot,  278 
hot  and  cold,  279 

peritonitis,  152 
Peptogenic  effects,  219 
Perforation  in  typhoid,  114 
Pericarditis,  147 
Peripheral  heart,  22,  26 

measures  which  stimulate,  171 
Peritonitis,  127,  280 

pelvic,  152 
Phagocytosis,  in  fevers,  98 

effects  of  anesthesia  on,  236 
cold  on,  62 
drugs  on,  100 
morphin  on,  237 
Pharyngitis,  137 
Phases  of  reaction,  13 
Phenacetin,  in  fevers,  101 
Phlebitis,  153 

Phosphoric  acid,  effect  of  cold  on,  69 
Physiologic  agents,  9 

effects,  principles  of,  9 

stimulants,  156 

therapy,  realm  of,  93 
Pilocarpin,  in  fevers,  101 
Pleurisy,  128,  146,  289 

complicating  typhoid,  114 
Plunge,  cold,  158 
Pneumonia,  127,  139,  280,  289 

complicating  typhoid,  114 
Poikilothermic  animals,  9 
Poisoning,  ivy,  139 

systemic,  203 
Poultices,  252 
Properties  of  water,  3 
Proctoclysis,  Murphy  method,  294 

absorption  of  fluid,  56 

in  surgical  collapse,  232 
Prostatitis,  155,  289 
Proximal  application,  42,  247 


306 


INDEX 


Psychic  attitude,  effect  on  reaction, 

15 

Puerperal  infection,  127,  152,  280 
Pulmonary  congestion,  198 

hemorrhage,  224 
Purin,  diathesis,  206 

a  cause  of  fever,  96 

effects  of  coffee  on,  217 

effect  of  cold  on,  67 

in  gout,  206 
Pyrexia,  see  fever 

Quassia  enema,  296 
Quinin,  enema,  297 

in  fevers,  101 

in  malaria,  117 

in  pneumonia,  143 

prophylactic  use  of,  117 

protozoan  immunity  to,  118 

Radiant  heat,  246 
Radiation,  heat  loss  by,  82 
Reaction,  11 

ability,  test  of,  15 

circulatory,  13,   25 

conditions  influencing,  14 

deep  reflex,  42 

inccmplete,  14 

in  blood  vessels,  25 

in  malaria,  121 

nervous,  13 

of  short  cold,  11 

phases  of,  13 

rationale  of,  11 

repeated,  14 

suppressed,  13 

thermic,  13 

time  factor  in,  12 

to  heat,  13 

types  and  degrees  of,  13 
Rectal  injection,  see  enemata 

irrigation,  292 

tenesmus,  194 

ulcer,  192 
Red  cells,  effect  of  cold  on,  59 

effect  of  heat  on,  59 
Reflex  arc,  34,  36,  37 

areas,  34,  38,  40 

effects,  33 

classes  of,  40 

Refrigerants,  in  fever,  101 
Resistant  gymnastics.  173 
Respiration,  73 

by  skin,  31 

Rest,  in  heart  disease,  171 
Retrostasis,  46 
Revulsion,  defined,  130 
Revulsive  compress,  244 

douche,  288 

sitz  bath,  265 
Rheumatic  fever,  148 


Rheumatism,  chronic  articular,  166, 
206 

with  emaciation,  209 

with  obesity,  208 
Romberg  and  Passler,  researches  of, 

98,  113,  141 
Rubner,  chart  on  heat  loss,  83 

experiments  of,  74 
Rubs 

alcohol,  257 

cold  towel,  158,  254 
in  typhoid,  110 

dripping  sheet,  158,  255 

dry,  261 

ice,  255,  111 

menthol,  257 

oil,  260 

vinegar  and  salt,  257 

wet  hand,  157,  254 

wet  sheet,  158,  254 

witchhazel,  257 
Rubs  and  frictions,  258 
Russian  bath,  271 

Saline  bath,  269 

sponge,  257 

Salpingitis,  127,  152,  280 
Salt  and  vinegar  rub,  257 
Salt  glow,  158,  255 
Salt,  relation  to  edema,  211 
Scarlet  fever,  123 
Schott  treatment,  173 
Schuller,  experiments  of,  33,  44 
Sciatica,  128,  289 
Sebaceous  glands,  30 
Sedative  effects,  40,  180 
Sedatives,  general,  180 

local,  182 

pure,  180 

tonic,  182 
Septicemia,  138 
Serum,  Flexner's,  150 
Shampoos,  274 
Sheet  pack,  wet,  281 

in  typhoid,  110 
Sheet' rub,  wet,  158,  254 

dripping,  158,  255 
Shock,  surgical,  228 
Shower  bath,  see  sprays 
Sinusoidal     electricity,     in    neuras- 
thenia, 165 

tub  bath,  268 
Sitz  bath,  264 
Skin,  17,  28 

heat  regulation  by,  31 

respiration  by,  31 

vicarious  functions  of,  29 
Soap-suds  enema,  295 

vaginal  irrigation,  298 
Soap  wash,  258 
Specific  heat,  52 


INDEX 


307 


Spinal  paralyses,  spastic,  187,  289 
Splanchnic  efferent  nerves,  40 

neurasthenia,  164 
Spleen,    effects   on    distribution    of 

blood  cells,  60 
Sponging,  256 
Sprains,  195 
Sprays,  285,  286 
Starch  enema,  2% 
Starling,  work  of,  51 
Stimulant  effects,  13,  40,  156,  177 
Stimulants,  156 

drug,  defined,  156 

intestinal,  178 

uterine,  178 

yesical,  178 
Stimuli,  mechanical,  7,  75 

thermic,  7 

Stomach,  reflex  arc  to,  37 
Stupes,  244 
Strychnin,  as  a  general  tonic,  80 

in  pneumonia,  144 

in  surgical  shock,  234 

in  typhoid,  113 

Sulphates,  effect  of  cold  on,  70 
Sun  baths,  in  anemia,  161 

in  neurasthenia,  164 
Sunstroke,  168 
Surgery,  after-treatment,  236 

hydrotherapy  in,  226 

immediate  care,  227 

preparatory  treatment,  226 

relation  to  physiologic  therapy,  94 
Surgical  shock,  228 

contributing  causes,  228 

drugs  in,  234 

hydrotherapy  in,  232 

treatment  of,  231 
Sweat  glands,  28 

in  nephritis,  29 

perspiratory  influences,  29 

vicarious  functions,  29 
Swedish  shampoo,  274 

Talcum  rub,  261 

Technique  of  hydrotherapy,  239 

Temperature,  common  names  of,  16 

nerves  of,  32 
Tenesmus,  194 
Therapeutics,  94 
Therapy,  basic  principles  of,  95 

physiologic,  realm  of,  93 

principles  of,  9 
Thermic  stimuli,  7 
Thermometers,  4,  5 
Thermotherapy,  3 
Throat  compress,  heating,  251 
Tobacco  blindness,  135 
Tonic  effects,  13,  156,  177 

frictions,  252 

sedatives,  182 


Tonics,  hydriatic  vasomotor,  172 
Tonsilitis,  137 

in  scarlet  fever,  123 
Towel  rub,  see  rubs 
Tracoma,  135 

Traube-Hering  waves,  22,  230 
Trauma,  relation  to  shock,  229,  235 
Trunk  pack,  heating,  283 

hot,  278 
Turkish  bath,  272 

shampoo,  274 
Turpentine  enema,  296 
Tympanites,  in  typhoid,  115 
Typhoid  fever,  108 

hot  treatment  in,  111 

cold  treatment  of,  109 

Ulcer,  duodenal,  192 

gastric,  192 

rectal,  192 

varicose,  289 
Urea,  effect  of  cold  on,  67 

in  uremia,  216 
Uremia,  215 

acute,  217 

Urethritis,  specific,  155,  289 
Uric  acid,  effect  of  caffein  on,  217 

effect  of  cold  on,  67 

effect  of  heat  on,  71 

endogenous,  in  gout,  215 

formation  and  destruction  of,  206 

Vaginal  irrigation,  297 
Vaginitis,  155 
Valvular  heart  disease,  169 
Vapor  bath,  272 
Varicose  ulcer,  289 
Vasomotor  center,  33,  36 

paralysis  of,  in  fevers,  99 

in  shock,  230 
Vasomotor  nerves,  18,  20 
Vasomotors,  effect  on  blood  vessels, 
21,  33 

failure  in  fevers,  99 
in  shock,  230 
in  typhoid,  113 
Vasomotor  tonics,  in  fevers,  98 

in  heart  disease,  172 

in  surgical  shock,  232 
Veno-pressor  mechanism,  231 
Vesical  stimulants,  178 

tenesmus,  194 

Vibration,  in  heart  disease,  172 
Vinaj  and  Maggiori,  experiments  of , 

76 

Vinegar  and  salt  rub,  257 
Vinegar  vaginal  irrigation,  299 
Viratrum  viride,  in  fevers,  100 . 

Warm-blooded  animals,  9 
Water,  expansion  of,  3,  4 


308  INDEX 

mineral,  8,  207,  209  Wet  sheet  pack,  281,  see  packs 
properties  of,  3  in  typhoid,  110 

Water  bottles,  hot,  245  Wet  sneet  rubs,  158,  254,  see 

Water  drinking,  cold,  effect  on  blood  White  cells,  see  leucocytes 

pressure,  58  Wint^rnitz  coil,  246 
effect  on  urea  excretion,  70  in  dyspepsia,  220 

in  dyspepsia.  221  in  typhoid,  111 

in  pneumonia,  143  Winternitz  pack,  246,  284 
in  surgery,  227,  237  in  dyspepsia,  220 

Wet  hand  rub,  157,  254,  see  rubs  Witchhazel  rub,  257 


' 


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WB520 
A131h 

1911 
Abbott,  George  Khapp. 

Hydrotherapy 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

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